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D PROGRAM CONSOLIDATED FO n Lit, TANKS UNDERGROUND STORAGE TANKS - TANK PAGE 2 Pae 3 of 7 VI.PIPING CONSTRUCTION(Check oil that apply) UNDERGROUND PIPING ABOVEGROUND PIPING SYSTEM TYPE ®1.PRESSURE D 2.SUCTION [13.GRAVITY 458. [11.PRESSURE D 2.SUCTION [13.GRAVITY 459. CONSTRUCTION/ D 1.SINGLE WALL D 3.LINED TRENCH ❑99.OTHER 460. O L SINGLE WALL D 95.UNKNOWN 462. MANUFACTURER ®2 DOUBLE WALL D 95.UNKNOWN D 2.DOUBLE WALL D 99.OTHER MANUFACTURER46i. MANUFACTURER 463. D 1.BARE STEEL D 6.FRP COMPATIBLE W/100%METHANOL [11.BARE STEEL D 6.FRP COMPATIBLE W1100%METHANOL D 2.STAINLESS STEEL D 7.GALVANIZED STEEL D 2.STAINLESS STEEL D 7.GALVANIZED STEEL D 3.PLASTIC COMPATIBLE WITH CONTENTS [195.UNKNOWN D 3.PLASTIC COMPATIBLE W/CONTENTS D 8.FLEXIBLE(HDPE) ❑99.OTHER ®4.FIBERGLASS D 8.FLEXIBLE(HDPE) D 99.OTHER [14.FIBERGLASS D 9.CATHODIC PROTECTION ❑5.STEEL W/COATING D 9.CATHODIC PROTECTION 464. D 5.STEEL W/COATING D 95.UNKNOWN 465. VII.PIPING LEAK DETECTION(Chock all that apply)(A dead tion ofthe monitoda8 pmman shall be suntanned to the local atomy.) UNDERGROUND PIPING ABOVEGROUND PIPING SINGLE WALL PIPING 466. SINGLE WALL PIPING 462 PRESSURIZED PIPING(Check all that apply): PRESSURIZED PIPING(Check all that apply): D 1. ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP [11. ELECTRONIC LAVE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP SHUT-OFF FOR LEAK, SYSTEM FAILURE,AND SYSTEM DISCONNECTION SHUT OFF FOR LEAK,SYSTEM FAILURE,AND SYSTEM DISCONNECTION +AUDIBLE AND VISUAL ALARMS. +AUDIBLE AND VISUAL ALARMS. [12. MONTHLY 0.2 GPH TEST [12. MONTHLY 0.2 GPH TEST [13. ANNUAL INTEGRITY TEST(0.1 GPH) [13. ANNUAL INTEGRITY TEST(0.1 GPH) D 4. DAILY VISUAL CHECK CONVENTIONAL SUCTION SYSTEMS CONVENTIONAL SUCTION SYSTEMS(Check all that apply) D 5. DAILY VISUAL MONITORING OF PUMPING SYSTEM+TRIENNIAL PIPING [15. DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM INTEGRITY TEST(0.1 GPH) SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): [16. TRIENNIAL INTEGRITY TEST(0.1 GPH) [17. SELF MONITORING SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): GRAVITY FLOW [17. SELF MONITORING [19. BIENNIAL INTEGRITY TEST(0.1 GPH) GRAVITY FLOW(Check all that apply): [19. DAILY VISUAL MONITORING [19. BIENNIAL INTEGRITY TEST(0.1 GPM SECONDARILY CONTAINED PIPING SECONDARILY CONTAINED PIPING PRESSURIZED PIPING(Check ail that apply): PRESSURIZED PIPING(Check all that apply): 10. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL 10. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL ALARMS AND(Check one) ALARMS AND(Check one) ❑a. AUTO PUMP SHUT OFF WHEN A LEAK OCCURS ❑a. AUTO PUMP SHUT OFF WHEN A LEAK OCCURS ®b.AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM ❑b.AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM DISCONNECTION DISCONNECTION Dc. NO AUTO PUMP SHUT OFF Dc. NO AUTO PUMP SHUT OFF ®11. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)WITH FLOW SHUT D 11 AUTOMATIC LEAK DETECTOR OFF OR RESTRICTION ❑12. ANNUAL INTEGRITY TEST(0.1 GPH) D 12. ANNUAL INTEGRITY TEST(0.1 GPH) SUCTION/GRAVITY SYSTEM SUCTION/GRAVITY SYSTEM [113. CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS [113, CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS EMERGENCY GENERATORS ONLY(Check all that apply) EMERGENCY GENERATORS ONLY(Check all that apply) [114. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF D 14. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF AUDIBLE AND VISUAL ALARMS AUDIBLE AND VISUAL ALARMS [315. AUTOMATIC LINE LEAK DETECTOR Do GPH TEST) WITHOUT FLOW D 15. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST) SHUT OFF OR RESTRICTION D 16. ANNUAL INTEGRITY TEST(0.1 GPH) ❑16. ANNUAL INTEGRITY TEST(0.1 GPH) ❑ 17. DAILY VISUAL CHECK D 17. DAILY VISUAL CHECK VII.DISPENSER CONTAINMENT DISPENSER CONTAINMENT 468. [11. FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE ❑4. DAILY VISUAL CHECK 469. DATE INSTALLED E12. CONTINUOUS DISPENSER PAN SENSOR+AUDIBLE AND VISUAL ALARMS D5. TRENCH/LINER MONITORING 06 O-7 03. CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR D 6. NONE DISPENSER+AUDIBLE AND VISUAL ALARMS IX.OWNER/OPERATOR SIGNATURE I certify[Dat t e g forma[ vided herejq is true and accurate to the best of my knowledge. SIGN O DATE: 470' 10 -s-os NAME OF WNER/OPERATOR(print): L L TITLE OF OWNER/OPERATOR: 1 „ S 472 rl" IV Permit Number(Agency use only) 473. 1 Pevtdt Approved By(Agency use only) 474. 1 Permit Expiration Date(Agency use only) 475. UPCF hwfwrc-b(1/99)-3/4 http://www.unidocs.org Rev.02/16/00