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UNIFIED PROGRAM CONSOLIDATED FORM TANKS UNDERGROUND STORAGE TANKS- TANK PAGE 2 Pae of VI.PIPING CONSTRUCTION(Check all that UNDERGROUND PIPING ABOVEGROUND PIPING SYSTEM TYPE 1.PRESSURE ❑2.SUCTION [13.GRAVITY 458. ❑1.PRESSURE ❑2.SUCTION ❑3.GRAVITY 459. CONSTRUCTION/ ❑1.SINGLE WALL [13.LINED TRENCH ❑99.OTHER 460. ❑L SINGLE WALL [195.UNKNOWN 462. MANUFACTURER 2 DOUBLE WALL ❑95.UNKNOWN ❑2.DOUBLE WALL ❑99.OTHER MANUFACTURER nqI M F( 461. MANUFACTURER 463. ❑1.BARE STEEL jo 6.FRP COMPATIBLE W/100%METHANOL ❑1.BARE STEEL ❑6.FRP COMPATIBLE W/100%METHANOL ❑2.STAINLESS STEEL ❑7.GALVANIZED STEEL ❑2.STAINLESS STEEL ❑7.GALVANIZED STEEL ❑3.PLASTIC COMPATIBLE WITH CONTENTS ❑95.UNKNOWN ❑3.PLASTIC COMPATIBLE W/CONTENTS ❑8.FLEXIBLE(HDPE) ❑99.OTHER ❑4.FIBERGLASS ❑8.FLEXIBLE(HDPE) ❑99.OTHER ❑4.FIBERGLASS ❑9.CATHODIC PROTECTION ❑5.STEEL W/COATING ❑9.CATHODIC PROTECTION 464. ❑5.STEEL W/COATING ❑95.UNKNOWN 465. VII.PIPING LEAK DETECTION Check all that ) A m of the mDaltoring Program shall be submitted in ftlocal .) UNDERGROUND PIPING ABOVEGROUND PIPING SINGLE WALL PIPING 466• SINGLE WALL PIPING 467. PRESSURIZED PIPING(Check all that apply): PRESSURIZED PIPING(Check all that apply): ❑1. ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP [31. ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP SHUT-OFF FOR LEAK,SYSTEM FAILURE,AND SYSTEM DISCONNECTION SHUT OFF FOR LEAK,SYSTEM FAILURE,AND SYSTEM DISCONNECTION +AUDIBLE AND VISUAL ALARMS. +AUDIBLE AND VISUAL ALARMS. ❑2. MONTHLY 0.2 GPH TEST ❑2. MONTHLY 0.2 GPH TEST [13. ANNUAL INTEGRITY TEST(0.1 GPH) ❑3. ANNUAL INTEGRITY TEST(0.1 GPH) ❑4. DAILY VISUAL CHECK CONVENTIONAL SUCTION SYSTEMS CONVENTIONAL SUCTION SYSTEMS(Check all that apply) ❑5. DAILY VISUAL MONITORING OF PUMPING SYSTEM+TRIENNIAL PIPING ❑5. DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM INTEGRITY TEST(0.1 GPM) SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): [16. TRIENNIAL INTEGRITY TEST(0.1 GPH) [17. SELF MONITORING SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): GRAVITY FLOW [17. SELF MONITORING [19. BIENNIAL INTEGRITY TEST(0.1 GPH) GRAVITY FLOW(Check all that apply): [18. DAILY VISUAL MONITORING [39. BIENNIAL INTEGRITY TEST(0.1 GPH) SECONDARILY CONTAINED 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. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL ALARMS AND(Check one) ALARMS AND(Check one) ❑a.AUTO PUMP SHUT OFF WHEN A LEAK OCCURS ❑a.AUTO PUMP SHUT OFF WHEN A LEAK OCCURS PR 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 0111. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)WITH FLOW SHUT ❑11.AUTOMATIC LEAK DETECTOR OFF OR RESTRICTION ❑12. ANNUAL INTEGRITY TEST(0.1 GPH) ❑12.ANNUAL INTEGRITY TEST(0.1 GPH) 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(Check all that apply) [114. 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 [115. AUTOMATIC LINE LEAK DETECTOR (3.0 GPH TEST) WITH UT FLOW [115.AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST) SHUT OFF OR RESTRICTION ❑l6. ANNUAL INTEGRITY TEST(0.1 GPH) [116.ANNUAL INTEGRITY TEST(0.1 GPH) [317. DAILY VISUAL CHECK ❑17.DAILY VISUAL CHECK VIII.DISPENSER CONTAINMENT DISPENSER CONTAINMENT 468. ❑1. FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE ❑4. DAILY VISUAL CHECK 469. DATE INSTALLED [12. CONTINUOUS DISPENSER PAN SENSOR+AUDIBLE AND VISUAL ALARMS El5. TRENCH/LINER MONITORING , 2 U CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR [16. NONE DISPENSER+AUDIBLE AND VISUAL ALARMS IX.OWNER/OPERATOR SIGNATURE I certify that the information provided herein is true and accurate to the best of my knowledge. SIGNATURE OF O Rr�TOR DATE: 0 4M n,/� NAME OF OWNER/OPERATOR(print): LiL TITLE OF OWNER/OPERATOR: 472.Y � Permit Number(Agency use only) /f 473. 1 Permit Approved By(Agency use only) 474. 1 Permit Expiration Date(Agency use only) 475. UPCF hwfwm-b(1/99)-3/4 httpJ/www.unidoes.org Rev.02/16/00