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IFIED PROGRAM CONSOLIDATED FORM TANK 4 PR# UNDERGROUND STORAGE TANKS - TANK PAGE 2 FAC# VI PIPING CONSTRUCTION(Check all.Ow apply) Page 3of3 UNDERGROUND PIPING ABOVEGROUND PIPING SYSTEMTYPE ❑ 1 PRESSURE ❑ 2 SUCTION PQ 3 GRAVITY 458 ❑ I PRESSURE ❑ 2 SUCTION ❑ 3 GRAVITY 459 CONSTRUCTION I SINGLE WALL 03 LINED TRENCH ❑ 99 OTHER 460 ❑ 1 SINGLE WALL ❑ 95 UNKNOWN 462 ❑2 DOUBLE WALL 095 UNKNOWN ❑ 2 DOUBLE WALL ❑ 99 OTHER MANUFACTURER 461 MANUFACTURER 463 1 BARE STEEL ❑ 6 FRP COMPATIBLE wl 1005E METHANOL ❑ I BARE STEEL CJ 6 FRP COMPATIBLE w/100%METHANOL ' ❑ 2 STAINLESS STEEL ❑ 7 GALVANIZED STEEL ❑ 2 STAINLESS STEEL ❑ 7 GALVANIZED STEEL ❑ PLASTIC COMPATIBLE W/CONTENTS ❑ 95 UNKNOWN ❑ PLASTIC COMPATIBLE W1 CONTkNTS [:195 UNKNOWN © 4 FIBERGLASS ❑ 8 FLEXIBLE(HDPE) ❑ 99 OTHER ❑ 4 FIBERGLASS ❑'B FLEXIBLE(HDP&) ❑ 99 OTHER © S STEEL WICOATING ❑ 9 CATHODIC PROTECTION 464 'El 5 STEEL WlCOATING ❑ 9 CATHODIC PROTECTION 465 VII PIPING LEAK DETECTION(Check all that apply)(A dmcnptmn of the tnonnonng program shall he submitted to the local agency) UNDERGROUND PIPING ABOVEGROUND PIPING SINGLE WALL PTPING 466 SINGLE WALL PIPING 467 ' PRESSURIZED PIPING(Check all that apply) PRESSURIZED PIPING(Check all that apply) [_1 i ELECTRONIC LINE LEAK DETECTOR 3 0 GPH TEST WWITF,j AUTO PUMP SHUT OFF ❑ I ELECTRONIC LINE LEAK DETECTOR 3 0 GPH TEST WITH AUTO PUMP SHU] OFF FOR LEAK SYSTEM FAILURE AND SYSTEM DISCONNECTION+AUDIBLE AND FOR LEAK SYSTEM FAILURE AND SYSTEM DISCONNECTION+AUDIBLE AND VISUAL ALARMS VISUAL ALARMS ❑ 2 MONTHLY 0 2 GPH TEST ❑ 3 ANNUAL INTEGRITY TEST(0 1 GPH) ❑ 2 MONTHLY 0 2 GPH TEST E] 3 ANNUAL INTEGRITY TEST(0 I GPH) ❑ 4 DAILY VISUAL CHECK CONVENTIONAL SUCTION SYSTEMS CONVENTIONAL SUCTION SYSTEMS(Check all that apply) ❑ 5 DAILY VISUAL MONITORING OF PUMPING SYSTEM+TRIENNIEAL PIPING ❑ 5 DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM ' INTEGRITY TEST(0 1 GPH) ❑ 6 TRIENNIAL INTEGRITY TEST(0 1 GPH) SAFE SUCTION SYSTEMS(NO VALUES IN BELOW GROUNDPIPING) SAFE SUCTION SYSTEMS(NO VALUES IN BELOW GROUNDPIPING) ❑ 7 SELF MONITORING ❑ GRAVITY FLOW 7 SELF MONITORING ' ❑ 9 BIENNIAL INTEGRITY TEST(0 1)GPH GRAVITY FLOW(Check all that apply) ❑ 8 DAILY VISUAL MONITORING ❑ 9 BIENNIAL INTEGRITY TEST(0 1)GPH SECONDARILY CONTAINED PIPING SECONDARILY CONTAINED PIPING RESSURIZED 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 WITH AUDIBLE AND VISUAL ALARMS AND(Check one) ALARMS AND(check.,,c) ' ❑ 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 ❑ c NO AUTO PUMP SHUT OFF ❑ c NO AUTO PUMP SHUT OFF ❑ I I AUTOMATIC LINE LEAK DETECTOR(3 0 GPH TEST)WITH FLOW SHU f OFF OR RESTRICTION ❑ I I AUTOMATIC LFAK D£FECTOR ❑ 12 ANNUAL INTEGRITY TEST(0 I GPH) ❑ 12 ANNUAL INTEGRITY TEST(0 1 G11H) SUCTION/GRAVITY SYSTEM SUCTION/GRAVITY SYSTEM ' ❑ 13 CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS ❑ 13 CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS EMERGENCY GENERATORS ONLY(Check all that apply) EMERGENCY GENERATORS ONLY(Chcek all that apply) ❑ 14 CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF* ❑ 14 CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF AUDIBLE AND VISUAL ALARMS AUDIBLE AND VISUAL ALARMS ' ❑ 15 AUTOMATIC LINE LEAK DETECTOR(3 0 GPH TEST)WITHOUT FLOW ❑ 15 AUTOMATIC LINE LEAK DETECTOR(3 0 GPH TEST)WITHOUT FLOW SHUT OFF OR RESTRICTION SHUT OFF OR RESTRICTION ❑ M ANNUAL fNTEGRITY TEST(0 1 GPH) ❑ M ANNUAL INTEGRITY TEST(0 1 GPH) ' [] 17 DAILY VISUAL CHECK ❑ 17 DAILY VISUAL CHECK VIII DISPENSER CONTAINMENT DISPENSER CONTAINMENT ❑ I FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE E] 4 DAILY VISUAL CHEC K DATEINSTALLED 468 ❑ 2 CONTINUOUS DISPENSER PAN SENSOR+AUDIBLE AND VISUAL ALARMS ❑ 5 TRENCH LINFR I MONITORING ' ❑ 3 CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT Of F FOR ❑ 6 NONE DISPENSER+AUDIBLE AND VISUAL ALARMS 469 IX OWNERlOPERATOR SIGNA7 URE I trrttfy that the mfomuttott pmvidedlymin is out and acc. tD the hest of my knowledge ILIlk 116. SIGNATUREO OWN TO DATE j z 470 ME FOWNE RATOR(p t) TITLE OF OWNERIOPERATORQ /J/ q 471 �( s! 472 Penmt N Mbcr(For local"se only) 473 Pcrmn Approved(For loci[we only) 474 Pcrmll ExpuatLon Date(Far local use only) 475 ' UPCF 02199 revised)