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•NIFIED PROGRAM CONSOLIDATED FOR. TANK: TA0170703 P PR#: PR0231707 FAC#: FA0003948 UNDERGROUND STORAGE TANKS -TANK PAGE 2 VL PIPING CONSTRUCTION(anact,au mat apply) Papa ofS UNDERGROUND PIPING ABOVEGROUND PIPING SYSTEM TYPE ❑ I.PRESSURE ❑ 2.SUCTION ❑ 3.GRAVITY 458 ❑ 1.PRESSURE ❑ 2.SUCTION ❑ 3.GRAVITY 459 CONSTRUCTION ❑I.SINGLE WALL ❑3.LINEDTRENCH El 99.OTHER 460 ❑ 1.SINGLE WALL 095.UNKNOWN 462 ❑2.DOUBLE WALL 095.UNKNOWN ❑ 2.DOUBLE WALL ❑ 99.OTHER MANUFACTURER 461 MANUFACTURER 463 E] I.BARESTEEL ❑6.FRP COMPATIBLE w/IWAMEPHANOL [3 1.BARE STEEL ❑6.FRP COMPATIBLE tall YMETHANOL ❑ 2.STAINLESS STEEL ❑7.GALVANIZED STEEL ❑ 2.STAINLESS STEEL ❑ 7.GALVANIZED STEEL ❑ PLASTIC COMPATIBLE W/CONTENTS ❑ 95.UNKNOWN ❑ PLASTIC COMPATIBLE W/CONTENTS ❑ 95.UNKNOWN ❑4.FIBERGLASS [18.FLEXIBLE(HDPE) ❑ ".OTHER ❑ 4.FIBERGLASS ❑ 8.FLEXIBLE(HDPE) ❑ 99.OTHER ❑ 5.STEEL W/COATING ❑9.CATHODIC PROTECTION a64 ❑ 5.STEEL W/COATING ❑9.CATHODIC PROTECTION 965 VOL PIPING LEAK DETECTION(Cnnack an that apply)(A decnplion ofine nioahocng pmgam:hall he antannea en the lad.Sant,.) UNDERGROUND PIPING ABOVEGROUND PIPING SINGLE WALL PIPING 466 SINGLE WALL PIPING PRESSURIZED PIPING(Check all that apply): PRESSURIZED PIPING(Check all that apply): 467 ❑ I.ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP SHUT OFF ❑ 1.ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP SHUT OFF FOR LEAK,SYSTEM FAILURE,AND SYSTEM DISCONNECTION+AUDIBLE AND FOR LEAK,SYSTEM FAILURE,AND SYSTEM DISCONNECTION+AUDIBLE AND VISUAL ALARMS. VISUAL ALARMS. ❑2.MONTHLY 0.2 GPH TEST ❑ 2.MONTHLY 0.2 GPH TEST ❑ 3.ANNUAL INTEGRITY TEST(0.1 GPH) ❑ 3.ANNUAL INTEGRITY TEST(0.1 GPH) ❑ 4.DAILY VISUAL CHECK CONVENTIONAL SUCTION SYSTEMS CONVENTIONAL SUCTION SYSTEMS(Check all that apply) ❑ 5.DAILY VISUAL MONITORING OF PUMPING SYSTEM+TRIENNIEAL PIPING ❑ S.DAILY VISUAL MONITORIPIG OF PIPING AND PUMPING SYSTEM INTEGRITY TEST(0.1 GPH) ❑ 6.TRIENNIAL INTEGRITY TEST(OA GPH) SAFE SUCTION SYSTEMS(NO VALUES IN BELOW GROUNDPIPING): SAFE SUCTION SYSTEMS(NO VALUES IN BELOW GROUNDPIPING): ❑7.SELF MONITORING ❑ 7.SELF MONITORING GRAVITY FLOW ❑9.BIENNIAL INTEGRITY TEST(0.1)GPH GRAVITY FLOW(Check all that apply): ❑ 8.DAILY VISUAL MONITORING ❑ 9.BIENNIAL INTEGRITY TEST(0.1)GPH SECONDARILY CONTAINED PIPING SECONDARILY CONTAINED PIPING PRESSURIZED PIPING(Check all that apply): PRESSURIZED PIPING(Check all that apply): 10.CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL 10.CONTINUOUS TURBINE SUMP SENSOR WUH AUDIBLE AND VISUAL ALARMS AND(tank nu) ALARMS AND(Clark one) ❑e.AUTO PUMP SHUT OFF WHEN A LEAK OCCURS ❑ a.AUTO PUMP SHUT Off WHEN A LEAK OCCURS ❑ It.AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM ❑ It.AUTO PUMP SHAT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM DISCONNECTION DISCONNECTION ❑ c.NO AUTO PUMP SHUT OFF ❑ C.NO AUTO PUMP SHUT OFF ❑ 11.AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)WITH FLOW SHUT OFF OR RESTRICTION El AUTOMATIC LEAK DETECTOR ❑ 12.ANNUAL INTEGRITY TEST(0.1 GPH) ❑ 12.ANNUAL INTEGRITY TEST(0.1 GPH) SUCTION/GRAVITY SYSTEM SUCTION/GRAVITY SYSTEM ❑ 13.CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS ❑ 13.CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS EMERGENCY GENERATORS ONLY(Ouuek all mat apply) EMERGENCY GENERATORS ONLY(Clark all that apply) ❑ 14.CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF* ❑ 14.CONTINUOUS SUMP SENSOR WITHOU AUTO PUMP SHUT OFF" AUDIBLE AND VISUAL ALARMS AUDIBLE AND VISUAL ALARMS ❑ 15.AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)WITHOUT FLOW ❑ 15.AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)WITHOUT FLOW SHUT OFF OR RESTRICTION SHUT OFF OR RESTRICTION ❑ 16.ANNUAL INTEGRITY TEST(0.1 GPH) ❑ 16.ANNUAL INTEGRITY TEST(0.1 GPH) ❑ V.DAILY VISUAL CHECK ❑ V.DAILY VISUAL CHECK VIII.DISPENSER CONTAINMENT DISPENSER CONTAINMENT ❑ 1.FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE ❑ 4.DAILY VISUAL CHECK DATE INSTALLED 468 2.CONTINUOUS DISPENSER PAN SENSOR AUDIBLE AND VISUAL ALARMS ❑ ❑ 5.TRENCH LINER/MONITORING ❑ 3.CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR ❑ 6.NONE DISPENSER+AUDIBLE AND VISUAL ALARMS 469 LY.OWNER/OPERATOR SIGNATURE 1 ertib that the hafamation pnMdol Mem is mu and accurate to mebeat ofmy kmwle*.. SIGNATURE OF OWNER/OPERATOR DATE 470 NAME OF OWNER/OPERATOR(print) TITLE OF OWNER/OPERATOR 471 472 I..INwibn(Fplotal.t.ty) 473 Pmrvt Approved(Fa lad use a�Y) 474 Pews Eapiranon Date(Fm local u Wy) 475 PT0006519 EE0000817 12/31/2003 UPCF(12/99 revised)