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IFIED PROGRAM CO'N SO L;DATED FORM TANKS UNDERGROUND STORAGE TANKS -TANK PAGE 2 V1.PIPING CONSTRUCTION(Check a9thaf appy)w use. r rz UNDERGROUND PIPING ABOVEGROUND PIPING SYSTEM TYPE ❑ t PRESSURE 2. SUCTION ❑ 3.GRAVITY ❑ 1.PRESSURE I-I/ ❑ 2. SUCTION . ❑ 3. GRAVITY CONSTRUCTIOW SINGLE WALL ❑ 9. LINED TRENCH ❑99. OTHER ❑ 1. SINGLE WALL ❑95. UNKNOWN MANUFACTURER ❑ 2, DOUBLE WALL ❑95.UNKNOWN ❑ 2. DOUBLE WALL 1199.OTHER MANUFACTURER MANUFACTURER .BARE STEEL ❑ e.FRP COMPATIBLE N 1W%METHANOL ❑ 1. BARESTEEL ❑ 8.FRPCOMPAMBLEW T0D%METHANOL MATERIALS AND ❑ 1 STAINLESSSTEEL ❑ 7.GALVANIZEDSTEEL ❑ 7.GALVANIZED STEEL CORROSION ❑ 2. STAINLESS STEEL PROTECTION ❑ 3. PLASTICCOMPATIBLEWITH CONTENTS ❑95. UNKNOWN ❑ 3. PLASTIC COMPATIBLE WITH CONTENTS ❑ B.FI-MBLE(HOPE) Q99.OTHER.' ❑ 4. FIBERGLASS ❑ 8. FLEXIBLE(HOPE) W. OTHER ❑ 4. FIBERGLASS ❑ 9.CATHODIC PROTECTION ,Cl 5. STEELWICOATING ❑ 9.CATHODIC PROTECTION ❑ 5. STEELW/COATING 095. UNKNOWN VII.PIPING LEAK OETECTIDN Ifeelratlfhefp ^� UNOERGROUND PIPING SINGLE WALL PIPING ABOVEGROUND PIPING PRESSURIZED PIPING(Checka9 fher.,tl9: - PRESSURIZED PIPING(CAeckWfMfapply):SINGLE WALL PIPING _ ❑ 1. ELECTRONIC LINE IfAK DETECTOR 3.0 GPM TEST WITH AUTO PUMP SHUT OFF FOR ❑' 1. ELECTRONIC LINE LEAK DETECTOR 3.0 GPM TEST WITH AUTO PUMP SHUT OFF FOR LEAK, LEAK,SYSTEM FAILURE,ANDSYSTEM DISCONNECTION+AUDIBLE AND VISUAL SYSTEM FAILURE,AND SYSTEM DISCONNECTION+AUDIBLE AND VISUAL ALARMS ALARMS ❑ 2.MONTHLY 0.2 GPH TEST ❑ 2. MONTHLY 0.2 GPM TEST ❑ 3.ANNUAL INTEGRITY TEST(0.1 GPM) ❑ 3.ANNUAL INTEGRITY TEST(0.1 GPM) ❑ 4. DAILYVISUALCHECK CONVENTIONAL SUCTION SYSTEMS: CONVENTIONAL SUCTION SYSTEMS(Check ad Mat appy): Cl S. DAILY VISUAL MONITORING OF PUMPING SYSTEM+TRIENNIAL PIPING INTEGRITY ❑ S. DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM TEST(0.1 GPM) El 6. TRIENNIAL INTEGRITY TEST(0.1 GPM) SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING):SELF MONITORING SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): . ❑ 7. SELF MONITORING GRAVITY FLOW. - - El9.BIENNIAL INTEGRITY TEST(0.1 GPM) - GRAVITY FLOW(Check ad Maf eppW: ❑ B. DAILY VISUAL MONITORING ❑ 9. BIENNIAL INTEGRITY TEST(0.1 GPM) SECONDARILY CONTAINED PIPING PRESSURIZED PIPING(Chack all Maf apply): SECONDARILY CONTAINED PIPING PRESSURIZED PIPING(Chack a9 Mat apply): 10. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUALAURMS AND (OharA one) 10.CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL ALARMS AND(ae one) ❑ A. AUTO PUMP SHUT OFF WHEN A LEAK OCCURS ❑ e.AUTO PUMP SHUT OFF WHEN A LEAK OCCURS ❑ b AUTO PUMP SHUT DISCONNECTION OFF FOR LEANS,SYSTEM FAILURE AND SYSTEM ❑ b_AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM DISCONNECTION ❑ c,NO AUTO PUMP SHUT OFF ❑ I NOAUTO PUMP SHUT OFF ❑ 11 AUTRESTRICTION L NE LEAK DETECTOR OD GPM TEST)WITH FLOW SHUT OFF OR ❑ 11.AUTOMATIC LEAK DETECTOR ' ❑ 12.ANNUAL INTEGRITYTEST(0.1 GPM) - ❑ 12.ANNUAL INTEGRITYTESTKAGPH) SULTIONIGRANTY SYSTEM: SUCTIONIGRAVITY-SYSTEM: ❑ 13.CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS ❑ 13.CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS EMERGENCY GENERATORS ONLY(Check as Met apply) 11 14. GENERATORS ONLY(Deck a9 Maf appy)14.CONTINUOUS SUMP SENSOR WITHOUTAUTO PUMP SHUT OFF+AUDIBLE AND ❑ 14. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF+AUDIBLE AND VISUAL VISUAL ALARMS 111S.AUTOMATIC UALARMS RESTRICTION NE LEAK DETECTOR GPM TEST)WTHOUT FLOW SHUT OFF OR ❑ 15.AUTOMATIC LINE LEAK DEFECTOR(3.0 GPM TEST) ❑ 18.ANNUAL INTEGRITY TEST IDA GPM) ❑ 15.ANNUAL INTEGRITY TEST IDA GPM) ' ❑ 17. DAILY VISUAL CHECK ❑ 17. DAILY VISUAL CHECK VIIL DISPENSER CONTAINMENT,° " y„' , DISPENSER CONTAINMENT ❑ 1 FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE ❑ 4, DAILY VISUAL CHECK D T INST D ❑ 2.CONTINUOUS DISPENSER PAN SENSOR+AUDIBLEANDVISUALALARMS - ❑ 5. TRENCH LINER/MONITORING ❑ 3.CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR DISPENSER+AUDIBLE AND VISUAL ALARMS ❑8. NONE OWNER)OPERATOR SIGNATURE I ceNfy Met Ma Iniwma5on pm tlW herein u hue aM a t a be a, SI TURE��O33FCWNER/ TOR DATE NAME ME P. I OFOWNEFJOPEf,,Alum Mira Permit Number(Forfocal use only) Permit Appmvetl(Fw k alux wry) Permit Eapira9on Data(For Intel ase onty) CUPAFORM(4199) FO(medy$WRCB Form B