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TTNTM.n PROTRR AM rnNRO1T.TnATRi3 FOTRNT TANks UNDERGROUND STORAGE TANKS - TANK PAGE 2 Pae of Vl.PIPING CONSTRUCTION(Chest an mar ) ABOVEGROUND PIPING UNDERGROUND PIPING 459. 12. moNTHLY TYPE ❑1.PRESSURE SUCTION ❑3.GRAVITY 45s. ❑1.PRESSURE ❑2.SUCTION ❑3.GRAVITY q62. RUCTION/ .SINGLE W ALL ❑3.f.OJED TRENCH ❑99.OTHER 460. ❑1.SINGLE WALL ❑95.UNKNOWN ACTURER 0 2.DOUBLE WALL ❑95.UMCNIOWN ❑'_.DOUBLE O 99.OTHER 463. 461. MA\'UFAC7LltER MANUFACTURER ❑6.FRP COMPATIBLE W/100%METHANOL RE STEEL ❑6.FRP COMPATIBLE W/I00%METHANOL ❑1.BARE STEEL [17.GALVANIZED STEEL ANIZED ❑2.STAINLESS STEEL AINLESS STEEL [17.WITH CONTENTS STEEL 8. 99.OT ASTIC COMPATIBLE WITH CONTENTS ❑95.UNKNOWN [:13.PLASTIC COMPATIBLE W/CONTENTS O 9.CATHODIC C(ROTECfION [14.FIBERGLASS ❑S.FLEXIBLE(HDPE) ❑99.OTHER ❑4.FIBERGLASS 95 UNKNOWN a65 464. O 5.STEEL W/COATING TEEL W/COATING ❑9.CATHODIC PROECTION VIL PIPING LEAK DETECTION(ChckIIft. 1)(A a^nr�^1°^60f0e ABOVEGROUND PIPING UNDERGROUND PIPING 467. 466. SINGLE WALL PIPINGLE W ALL PIPING PRESSURIZED PIPING(Check all that apply): URIZED PIPING(Check all that apply):SELECTRONIC LINE LEAK FRTT.OFF OR LEAK EM FAIOURE H AUTO PUMP AND SYS EM ISCONNECT ON ❑1 SHU OFFFOR. ELECTRONIC LLE.AK SYSTEM FAIILURE,GAND SYSTEM DISCONNECTION -.AUDIBLE.A.\TD VISUAL ALARMS.+AUDIBLE AND VISUAL ALARMS. 2 \IONTHLY 0.2 GPH EST MONTHLY 0.2 GPH TEST ❑3. ANNUAL L\TEGRTTT TE57(0.1 GPH) [33. ANNUAL INTEGRITY TEST(0.1 GPH) [34, DAILY VISUAL CHECK CONVENTIONAL SUCTION SYSTEMS(Check all that apply) CONVENTIONAL SUCTION SYSTEMS ❑5. DAILY VISUAL MONITORING OF PUMPING SYSTEM+TRIENNIAL PIPING C35. DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM INTEGRITY TEST(0.1 GPH) SAFE SUCTION SYSTEMS(NO VALVES M BELOW GROUND PIPING): SFE SUCTION SYS E f (\5 OVALVES M BELOW GROUND PiPMG): SELF MONITORING El 7. SELF MONITORING GRAVITY FLOW GRAVITY FLOW(Chale a0 that apply): ❑9. BIENNIAL INTEGRITY TEST(0.1 GPH) E]8. DAILY VISUAL MOITTORLNG [:19. BIENNIAL INTEGRITY TEST(0.1 GPH) SECONDARILY COSTALYED 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. ROAR SOUS(LRBL-E S p SENSOR WITH AUDIBLE AND VI SUAL ALARMS AND(Check one) ❑a. ALTO PUNT SHUT OFF WHEN A LEAK OCCURS ,3 a. AUTO PUMP SHUT OFF WHEN A LEAK OCCURS ❑b.AUTO PIMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM Ob. DAL;ro ISCOM,,T SH'T OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM DISCONNECTION Oc. NO AUTO PIMP SHUT OFF (]c. NO AUTO PIMP SHUT OFF ❑11. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH EST)WITH FLOW SHUT ❑11. AUTOMATIC LEAK DETECTOR OFF OR RESTRICTION ❑12 ANNUAL INTEGRITY TEST(0.1 GPH) ❑12. ANNUAL INTEGRITY TEST(0-1 GPI SUCTION/GRAVITY SYSTEM . SUCTION/GRAVITY SYSTEM 13.CONTINUOUS SL;-MP SENSOR+AUDIB LE AND VISUAL ALARM ❑13. CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS EMERGENCY ERGENCY GENERATORS ONLY(Check all that apply) EMERGENCY GENERATORS ONLY(Check all that apply) [114. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF 13.CONTINUOUS SL- .0 WITHOUT AUTO PUMP SHUT OFF AUDIBLE AND VISUAL ALARMS AUDIBLE AND VISUAL ALARMS [315. AUTOMATIC LINE LEAK DETECTOR (3.0 GPH TEST) WITHOUT FLOW ❑I5.AUTOMATIC LI.NEIcA1c DETECTOR(3.0 GPH EST) SHUT OFF OR RESTRICTION ❑16.ANNUAL INTEGIUIY TEST(0.1 GPH) r]16. ANNUAL INTEGRITY TEST(0.1 GPH) 017.DAILY VISUAL CHECK [317. DAILY VISUAL CHECK WI.D3SPENSER CONTpDMTENT �4 DAILY VISUAL CHECK 469. DISPENSER CONTAINMENT 469. []1. FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE DATE fNSTALLED ❑2. CONTINUOUS DISPENSER PAN SENSOR,AUDIBLE AND VISUAL ALARMS ]_-15. TRENCHUNER MONITORING E33. CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR [j 6. NONE Ny DISPENSER+AUDIBLE AND VISUAL ALARMS Y"- D(.OWNER/OPERATOR SIGNATURE 1 certify that the information provided herein is true and accurate to the best of my knowledge. 470 SIGNATU E FOWN R/ PETRr ^ C DATE: SIGNATYfE FO:W C/ 472. TITLE OF OK R/OPERATOR: NAME F WNER/OP Off( a _( 47 l Expiration Date(Agency use Only) 475. Permit Number(Agency use only) P<rtnil APPmve y(Agrncy use only) (1/99).3/4 http://www.unidoc&org Rev.02/16/00