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TW'TF.T) PRO( --RAM C0N.C()T.TT)AT1WD FnRMF TANKS UNDERGROUND STORAGE TANKS - TANK PAGE 2 of SINGLE WALL PIPING 466. PRESSURIZED PIPING (Check all that apply): ❑ I. ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP SHUT-OFF FOR LEAK, SYSTEM FAILURE, AND SYSTEM DISCONNECTION + AUDIBLE AND VISUAL ALARMS. ❑ 2. MONTHLY 0.2 GPH TEST E:13. ANNUAL INTEGRITY TEST (0.1 GPH) CONVENTIONAL SUCTION SYSTEMS ❑ 5. DAILY VISUAL MONITORING OF PUMPING SYSTEM + TRIENNIAL PIPING INTEGRITY TEST (0.1 GPH) SAFE SUCTION SYSTEMS (NO VALVES IN BELOW GROUND PIPING): ❑ 7. SELF MONITORING GRAVITY FLOW ❑ 9. BIENNIAL INTEGRITY TEST (0.1 GPH) SECONDARILY CONTAINED PIPING PRESSURIZED PIPING (Check all that apply): 10. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL ALARMS AND (Check one) �G❑ a AUTO PUMP SHUT OFF WHEN A LEAK OCCURS Q9,b. AUTO PUMP SHUT OFF FOR LEAKS, SYSTEM FAILURE AND SYSTEM `` DISCONNECTION ❑c. NO AUTO PUMP SHUT OFF 11. AUTOMATIC LINE LEAK DETECTOR (3.0 GPH TEST) WITH FLOW SHUT ///AAA OFF OR RESTRICTION [:112. ANNUAL INTEGRITY TEST (0.I GPH) SUCTION/GRAVITY SYSTEM ❑ 13. CONTINUOUS SUMP SENSOR+ AUDIBLE AND VISUAL ALARMS EMERGENCY GENERATORS ONLY (Check all that apply) ❑ 14. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF AUDIBLE AND VISUAL ALARMS ❑ 15. AUTOMATIC LINE LEAK DETECTOR (3.0 GPH TEST) WITHOUT FLOW SHUT OFF OR RESTRICTION ❑ 16. ANNUAL INTEGRITY TEST (0.1 GPH) E:117. DAILY VISUAL CHECK SINGLE WALL PIPING 467 PRESSURIZED PIPING (Check all that apply): ❑ 1. ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP SHUT OFF FOR LEAK, SYSTEM FAILURE, AND SYSTEM DISCONNECTION + AUDIBLE AND VISUAL ALARMS. ❑ 2. MONTHLY 0.2 GPH TEST [13. ANNUAL INTEGRITY TEST (0.1 GPH) ❑ 4. DAILY VISUAL CHECK CONVENTIONAL SUCTION SYSTEMS (Check all that apply) ❑ 5. DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM E16. TRIENNIAL INTEGRITY TEST (0.1 GPH) SAFE SUCTION SYSTEMS (NO VALVES IN BELOW GROUND PIPING): ❑ 7. SELF MOMTORING GRAVITY FLOW (Check all that apply): [18. DAILY VISUAL MONITORING E39. BIENNIAL INTEGRITY TEST (0.1 GPH) SECONDARILY CONTAINED PIPING PRESSURIZED PIPING (Check all that apply): 10. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL ALARMS AND (Check one) ❑ a. AUTO PUMP SHUT OFF WHEN A LEAK OCCURS ❑ b. AUTO PUMP SHUT OFF FOR LEAKS, SYSTEM FAILURE AND SYSTEM DISCONNECTION ❑c. NO AUTO PUMP SHUT OFF ❑ 11. AUTOMATIC LEAK DETECTOR ❑ 12. ANNUAL INTEGRITY TEST (0.1 GPH) SUCTION/GRAVITY SYSTEM ❑ 13. CONTINUOUS SUMP SENSOR + AUDIBLE AND VISUAL ALARMS EMERGENCY GENERATORS ONLY (Check all that apply) ❑ 14. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF AUDIBLE AND VISUAL ALARMS ❑ 15. AUTOMATIC LINE LEAK DETECTOR (3.0 GPH TEST) ❑ 16. ANNUAL INTEGRITY TEST (0.1 GPH) ❑ 17. DAILY VISUAL CHECK VIIL DISPENSER CONTAINMENT DISPENSER CONTAINMENT 468. p 1. FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE DATE INSTALLED ❑ 2. CONTINUOUS DISPENSER PAN SENSOR + AUDIBLE AND VISUAL ALARMS (q q-1 �3. CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR ` DISPENSER + AUDIBLE A: 4D VISi1AL ALARMS IX. OWNER/OPERATOR SIGNATURE certify that the information provided herein is true and accurate to the best of my knowledge. SIGNATURE OF OWNER/OPERATOR DATE: ,L1ll +j ❑ 4. DAILY VISUAL CHECK 469. ❑ 5. TRENCH/LINER MONITORING '_-] 6. NONE 470. TITLE OF OWNER/OPERATOR: 472. NAME OF OWNER/OPERATOR (print): Ku�p� C. SN �-r� � mW K GTIL IC" I Pernut Number (Agency use only) 477 1 Pemut Approved By (Agency use only) 474 1 Permit Expiration Date (Agency use only) 475. UPCF hwfwre-b (1/99) - 3/4 http://www.unidoes.org Rev. 02/16/00 VI.PLPINGCONSTRUCTION (Check all that apply) UNDERGROUND PIPING ABOVEGROUND PIPING SYSTEM TYPE L PRESSURE [12. SUCTION ❑ 3. GRAVITY 459 ❑ 1. PRESSURE ❑ 2. SUCTION ❑ 3. GRAVITY 459. CONSTRUCTION/ ❑ 1. SINGLE WALL ❑ 3. LINED TRENCH ❑ 99. OTHER 460. ❑ 1. SINGLE WALL ❑ 95. UNKNOWN 462. MANUFACTURER 19 2 DOUBLE WALL ❑ 95. UNKNOWN ❑ 2. DOUBLE WALL ❑ 99. OTHER MANUFACTURER AMERON 461. MANUFACTURER 463. ❑ 1. BARE STEEL ❑ 6. FRP COMPATIBLE W/100% METHANOL ❑ I. BARE STEEL [:16. FRP COMPATIBLE W/100% METHANOL ❑ 2. STAINLESS STEEL ❑ 7. GALVANIZED STEEL ❑ 2. STAINLESS STEEL ❑ 7. GALVANIZED STEEL [13. PLASTIC COMPATIBLE WITH CONTENTS ❑ 95. UNKNOWN ❑ 3. PLASTIC COMPATIBLE W/ CONTENTS ❑ 8. FLEXIBLE (HDPE) [199. OTHER ►g4. FIBERGLASS /❑'5. [18. FLEXIBLE (HDPE) El 99. OTHER ❑ 4. FIBERGLASS ❑ 9. CATHODIC PROTECTION STEEL W/COATING ❑ 9. CATHODIC PROTECTION 464. ❑ 5. STEEL W/COATING ❑ 95. UNKNOWN 465. - � .- VII. PIPING LEAK DETECTION (Check all that apply) (A descri iioii of the monitoring pto ` 'shall lie�submined.foandlocal agency.) - - UNDERGROUND PIPING ABOVEGROUND PIPING SINGLE WALL PIPING 466. PRESSURIZED PIPING (Check all that apply): ❑ I. ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP SHUT-OFF FOR LEAK, SYSTEM FAILURE, AND SYSTEM DISCONNECTION + AUDIBLE AND VISUAL ALARMS. ❑ 2. MONTHLY 0.2 GPH TEST E:13. ANNUAL INTEGRITY TEST (0.1 GPH) CONVENTIONAL SUCTION SYSTEMS ❑ 5. DAILY VISUAL MONITORING OF PUMPING SYSTEM + TRIENNIAL PIPING INTEGRITY TEST (0.1 GPH) SAFE SUCTION SYSTEMS (NO VALVES IN BELOW GROUND PIPING): ❑ 7. SELF MONITORING GRAVITY FLOW ❑ 9. BIENNIAL INTEGRITY TEST (0.1 GPH) SECONDARILY CONTAINED PIPING PRESSURIZED PIPING (Check all that apply): 10. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL ALARMS AND (Check one) �G❑ a AUTO PUMP SHUT OFF WHEN A LEAK OCCURS Q9,b. AUTO PUMP SHUT OFF FOR LEAKS, SYSTEM FAILURE AND SYSTEM `` DISCONNECTION ❑c. NO AUTO PUMP SHUT OFF 11. AUTOMATIC LINE LEAK DETECTOR (3.0 GPH TEST) WITH FLOW SHUT ///AAA OFF OR RESTRICTION [:112. ANNUAL INTEGRITY TEST (0.I GPH) SUCTION/GRAVITY SYSTEM ❑ 13. CONTINUOUS SUMP SENSOR+ AUDIBLE AND VISUAL ALARMS EMERGENCY GENERATORS ONLY (Check all that apply) ❑ 14. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF AUDIBLE AND VISUAL ALARMS ❑ 15. AUTOMATIC LINE LEAK DETECTOR (3.0 GPH TEST) WITHOUT FLOW SHUT OFF OR RESTRICTION ❑ 16. ANNUAL INTEGRITY TEST (0.1 GPH) E:117. DAILY VISUAL CHECK SINGLE WALL PIPING 467 PRESSURIZED PIPING (Check all that apply): ❑ 1. ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP SHUT OFF FOR LEAK, SYSTEM FAILURE, AND SYSTEM DISCONNECTION + AUDIBLE AND VISUAL ALARMS. ❑ 2. MONTHLY 0.2 GPH TEST [13. ANNUAL INTEGRITY TEST (0.1 GPH) ❑ 4. DAILY VISUAL CHECK CONVENTIONAL SUCTION SYSTEMS (Check all that apply) ❑ 5. DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM E16. TRIENNIAL INTEGRITY TEST (0.1 GPH) SAFE SUCTION SYSTEMS (NO VALVES IN BELOW GROUND PIPING): ❑ 7. SELF MOMTORING GRAVITY FLOW (Check all that apply): [18. DAILY VISUAL MONITORING E39. BIENNIAL INTEGRITY TEST (0.1 GPH) SECONDARILY CONTAINED PIPING PRESSURIZED PIPING (Check all that apply): 10. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL ALARMS AND (Check one) ❑ a. AUTO PUMP SHUT OFF WHEN A LEAK OCCURS ❑ b. AUTO PUMP SHUT OFF FOR LEAKS, SYSTEM FAILURE AND SYSTEM DISCONNECTION ❑c. NO AUTO PUMP SHUT OFF ❑ 11. AUTOMATIC LEAK DETECTOR ❑ 12. ANNUAL INTEGRITY TEST (0.1 GPH) SUCTION/GRAVITY SYSTEM ❑ 13. CONTINUOUS SUMP SENSOR + AUDIBLE AND VISUAL ALARMS EMERGENCY GENERATORS ONLY (Check all that apply) ❑ 14. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF AUDIBLE AND VISUAL ALARMS ❑ 15. AUTOMATIC LINE LEAK DETECTOR (3.0 GPH TEST) ❑ 16. ANNUAL INTEGRITY TEST (0.1 GPH) ❑ 17. DAILY VISUAL CHECK VIIL DISPENSER CONTAINMENT DISPENSER CONTAINMENT 468. p 1. FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE DATE INSTALLED ❑ 2. CONTINUOUS DISPENSER PAN SENSOR + AUDIBLE AND VISUAL ALARMS (q q-1 �3. CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR ` DISPENSER + AUDIBLE A: 4D VISi1AL ALARMS IX. OWNER/OPERATOR SIGNATURE certify that the information provided herein is true and accurate to the best of my knowledge. SIGNATURE OF OWNER/OPERATOR DATE: ,L1ll +j ❑ 4. DAILY VISUAL CHECK 469. ❑ 5. TRENCH/LINER MONITORING '_-] 6. NONE 470. TITLE OF OWNER/OPERATOR: 472. NAME OF OWNER/OPERATOR (print): Ku�p� C. SN �-r� � mW K GTIL IC" I Pernut Number (Agency use only) 477 1 Pemut Approved By (Agency use only) 474 1 Permit Expiration Date (Agency use only) 475. UPCF hwfwre-b (1/99) - 3/4 http://www.unidoes.org Rev. 02/16/00