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D PROGRAM CONSOLIDATED FO TANKS UNDERGROUND STORAGE TANKS - TANK PAGE;2 Pa c of VI.PIPING CONSTRUCTION(cht,k all that ly) UNDERGROUND PIPING ABOVEGROUN;PIPING SYSTEM TYPE ❑ 1.PRESSURE ❑2.SUCTION 113.GRAVITY 45a. 111.PRESSURE ❑2.SUCTION ❑3.GRAVITY 459, CONSTRUCTION/ L SINGLE WALL [13.LINED TRENCH ❑99.OTHER 460. [11.SINGLE WALL ❑95.UNKNOWN 462, MANUFACTURER 2 DOUBLE WALL ®95.UNKNOWN ❑2.DOUBLE WALL ❑99.OTHER MANUFACTURER 461. MANUFACTURER 463. ❑L BARE STEEL ❑6.FRP COMPATIBLE W/100%METHANOL ❑ 1.BARE STEEL ❑6.FRP COMPATIBLE W/100%METHANOL ❑2.STAINLESS STEEL ❑7.GALVANIZED STEEL ❑2.STAINLESS STEEL ❑7.GALVANIZED STEEL [13.PLASTIC COMPATIBLE WITH CONTENTS E 95.UNKNOWN ❑3.PLASTIC COMPATIBLE W/CONTENTS ❑S.FLEXIBLE(HDPE) [199,OTHER ❑4.FIBERGLASS ❑S.FLEXIBLE(HDPE) ❑99.OTHER ❑4.FIBERGLASS [19.CATHODIC PROTECTION ❑5.STEEL W/COATING [19.CATHODIC PROTECTION 464. ❑5.STEEL W/COATING [195.UNKNOWN 465. VIII PIPING LEAK DETECTION(Check all that I)(A dcscntion orthe rronioring program shall he submitted to the localaeta UNDERGROUND PIPING ABOVEGROUND PIPING SINGLE WALL PIPING 466 SINGLE WALL PIPING 467 PRESSURIZED PIPING(Check all that apply): PRESSURIZED PIPING(Check all that apply): ❑ 1. ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WIT AUTO PUMP ❑ 1. ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP SMUT-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 ❑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) [15. 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 GER) [17. SELF MONITORING SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): GRAVITY FLOW ❑7. SELF MONITORING ❑9. BIENNIAL INTEGRITY TEST(0.1 GPH) GRAVITY FLOW(Check all that apply): ❑S. 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 WIT F AUDIBLE AND VISUAL ALARMS AND(Check one) ALARMS AND(Check ane) ❑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 Oc. NO AUTO PUMP SHUT OFF ❑c. NO AUTO PUMP SHUT OFF ❑ 11. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)WITH FLOW SHUT 0 11 AUTOMATIC LEAK DETECTOR OFF OR RESTRICTION ❑12. ANNUAL INTEGRITY TEST(0.1 GPH) [112. ANNUAL INTEGRITY TEST(0.1 GPIs) 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) ❑14. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF ❑ 14. CONTINUOUS SUMP SENSOR WITH AUTO PUMP SHUT OFF AUDIBLE AND VISUAL ALARMS AUDIBLE AND VISUAL ALARMS ❑15. AUTOMATIC LINE LEAK DETECTOR (3.0 GPH TEST) WITHOUT FLOW [1 15. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST) SHUT OFF OR RESTRICTION [116, ANNUAL INTEGRITY TEST(0.1 GPH) ❑ 16. ANNUAL INTEGRITY TEST(0.1 GPH) ❑17. DAILY VISUAL CHECK ❑ 17. DAILY VISUAL CHECK VOL.DISPENSER CONTAINMENT DISPENSER CONTAINMENT 411 ❑ I. FLOAT MECHANISM THA"f SHUTS OFF SHEAR VALVE E14. DAILY VISUAL CHECK 469. DATE INSTALLED ❑2. CONTINUOUS DISPENSER PAN SENSOR+AUDIBLE AND VISUAL ALARMS ❑5. TRENCH/LINER MONITORING ❑3. CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR E 6. NONE DISPENSER+AUDIBLE AND VISUAL ALARMS IN.OWNER/OPERATOR SIGNATURE I certify that the informati ro e erein is Vnd apZcate to the best of my knowledge. SIGNATURE OF OWNS E DATE:04-23-2004 470_ NAME OF OWNER/OP TOR(print): CHRISTOPHER MILLER TITLE OF OWNER/OPERATOR: AGENT FOR OWNER(AGE) 472, Permit Number(Agency use only) 473. 1 Permit Approved By(Agency use only) 474 1 Permit Expiration Date(Agency use only) 475. UPCF hwfwre-b(1/99)-3/4 http;H/ .unidoes.org Rev.02/16/00