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T 1N I 111F.n PRO"AM CANR(17.TTIATF.71 F(1RM TANKS UNDERGROUND STORAGE TANKS -TANK PAGE 2 Pa e of VI.PIPING CONSTRUCTION(cmt an the Ir) ABOVEGROUND PIPING UNDERGROUND PIPING +59. SUCTION ❑3.GRAVITY +Ss. ❑ 1.PRESSURE ❑2.SUCTION ❑3.GRAVITY I.PRESSURE 95.UNKNOWN +62. SYSTEM TYPE ❑ 66d. ❑l.SINGI.E WALL ❑ CONSTRUCTION/ .SINGLE WALL ❑3.LINED TRENCH ❑99.OTHER ❑2.DOUBLE W ALL ❑99.OTHER MANUFACTURER [12.DOUBLE WALL ❑95.UNKNOWN +63. 661. M.L\-UFAC7URER MANUFACTURER ❑6.FRP COMPATIBLEW/100'/.METHANOL Vr B�STEEL ❑6.FRP COMPATIBLE W/l00/METHANOL ❑2.BARE STEEL LESS STEEL ❑7.GALVANIZED STEEL M' 99.OTHER ❑2.STAINLESS STEEL ❑7.GALVANIZED STEEL 4.FIBERGLASS ❑9.CATHODIC PROTECTION ❑3.PLASTIC COMPATIBLE WITH CONTENTS ❑95.UNKNOWN ❑3.PLASTIC COMPATIBLE W/CO\TENTS ❑e.FLEXIBLE(HOPE) 46s ❑4.FIBERGLASS ❑6.FLEXIBLE(HDPE) ❑99.OTHER dba ❑5 STEEL W/COATING ❑95.UNKNOWN E]5.STEEL W/COATING ❑9.CATHODICPROTECTION rme arnaahs rR9s*a^shall be-heated to the I-W VII.PIPING LEAK DETECCION(Chat an mat 1)(A dee^ '°"oABOVEGROIFND PIING 467. UNDERGROUND PAWALL+66. SINGLE ALL PIPING SINGLE WALL PIPING PRESSURIZED PIPING(Check all that apply) AUTO PUMP PRESSURIZED PIPING(Check all that apply): ❑1. ELECTRONIC LAE LEAK DETECTOR ❑1. ELECTRONSYSTEM FAILURR IC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP GPH TEST WITH OFF FOR LEAK. E.AND SYSTEM DISCONNECTION SHUT-OFF FOR LEAK,SYSTEM FAILURE,AND SYSTEM DISCONNECTION _AUDIBLE.AND VISUAL ALARMS. +AUDIBLE AND VISUAL ALARMS. ❑2 NSp\-THEY 0.2 GPH TEST [12. MONTHLY 0.2 GPH TEST ❑3 A\.\.UAL L\-TEGIUTY TEST(0.1 GPH) ❑3. ANNUAL INTEGRITY TEST(0.1 GPH) ❑4. DAILY VISUAL CHECK CONVENTIONAL SUCTION SYSTEMS(Check all that apply) CONVENTIONAL SUCTION SYSTEMS TI ON MONITORING OF PUMP TEM INTEGRITY TESING SYSTEM+TRIENNIAL PIPING [35. DAILY VISUAL MONTfORLNG OF PIPING AND PUMPING SYS ❑5. DAILY VISUAL [3 6. I SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): S INTEGRITY TEST(0.1 GPH) SAFE SUUCTICTIONNSYSTEMS(NO VALVES IN BELOW GROUND PIPING): SELF MONITORING [37, SELF MONITORING GRAVITY FLOW GRAVITY FLOW(Cbeck all that apply): ❑9 BIENNIAL INTEGRITY TEST(0.1 GPH) ❑S DAILY VISUAL MONITORING ❑9. BIENNIAL INTEGRRY TEST(0.I GPH) SECONDARILY CONTALN"ED PIPING SECONDARILY CONTAINED PIPING PRESSURIZED PIPING(Check 16 that apply): PRESSURIZED PIPING(Check all that apply): 10. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL 10. CONTINUOUS(�kom) P SENSOR WITH ALDIBLE AND VISUAL ALARMS AND(Check one) ❑a. ALTO PUSff SHUT OFF WHEN A LEAK OCCURS L AUTO PUMP SHUT OFF WHEN A LEAK OCCURSb. ALTO PUSff SHIT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM ❑b. AUTO PUMP SHUT OFF FOR LEAKS.SYSTEM FAILURE AND SYSTEM [I b. 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 ❑11.AUTOMATIC LEAK DETECTOR OFF OR RESTRICTION ❑12.ANNUAL INTEGRITY TEST(0.1 GYM ❑12. ANNUAL INTEGRITY TEST(0.1 GPH) - SUCTION/GRAVITY SYSTEM. - SUCTION/GRAVITY SYSTEM 13. CONTIN'Ii0U5 S(.3SP SENSOR+AUDIBLE AND VISUAL AL ARMS ❑13. CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS ❑EMERGENCY GENERATORS ONLY(Check all that apply) EMERGENCY GENERATORS ONLY(Check all that apply) AUTO PUMP SHUT OFF AUTO PUMP ❑14.CONTINUOUS SUMP SENSOR WITHOUT [3 14. CONTINUOUS SUMP SENSOR WITHOUT SENT OFF AUDIBLE AND VISUAL ALARMS AUDIBLE AND VISUAL ALARMS ❑15. AUTOMATIC LINE LEAK DETECTOR (3.0 GPH TEST) WWI HOUT FLOW ❑I5.AUTON LINE LEAK DETECTOR(3-0 GPH SHUT OFF OR RESTRICTION ❑16.ANNUAL INTEGRITY TEST(0.1 GPT!) ❑16. ANNUAL INTEGRITY TEST(0.1 GPH) ❑17.DAILY VISUAL CHECK ❑17. DAILY VISUAL CHECK VIII.DISPENSER CONTAINMENT ❑q DAILY VISUAL CHECK 469. DISPENSER CONTAINMENT +6s. ❑1. FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE DATE IN^STAR 02. CONTINUOUS DISPENSER PAN SENSOR+AUDIBLE AND VISUAL ALARMS ❑5. TRENCH/LINER MONITORING [13. CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR ❑6. NONE DISPENSER+AUDIBLE AND VISUAL ALARMS IX.OWNER/OPERATOR SIGNATURE 1 certify tIt the information provided ein is true and accurate to the best of my knowledge. +70. SI A EOFOWN O R DATE: ZO B y X 672. TI OF OWNER/OP TO e AME F ER/60P 67s. Perm& Num er(Agency we only) Pennll Approve y(Agency a eely) 6t Expiation Dam(Agency uu only) Rev.02116/00 http://www.unidocs.org UPCF hwfwrc-b(1/99)-314