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SEB-07-2001 WED 03;46 PM QUIK STOP MKTS INC FAX NO. 5106571544 r <br /> UNIFIED PROGRAM CONSOLIDATED FORM TANK <br /> UNDERGROUND STORAGE TANKS -- TANK PAGE 2 -7 <br /> V1.PIPING CONSTRUCTION(Check all uuf apply) <br /> --" UNUCRGh0UN0 PIPING�-� A80VEGROUNO PIPING <br /> _ baVITY 41 <br /> v�r_M i r c (�i P trCPURE� 1.SUCTION w ❑0•GRAVITY SSB 1 PIiCSSURE ❑2. SUCTION ❑3 Gr <br /> CCN:iR'J (ICI: ❑1.SINGI E WALL [�3.LINED l IL@NCIH [500.OTHER /60 1.SINGLE WALL <br /> ❑95.UNKNOWN rr <br /> k4:'rJG l".(n 50 2 DOUBLE WALL ❑9E.UNKNOWN <br /> (]2.DOUBLE WAI L Q 99 OTI if R <br /> 401 MANUFACTURER <br /> WANUFACIU'RER AO Smith O.fRPCOMPAT13LE wn,cr-,LLr �:• <br /> 5.FRP COMP TIBLE w1100% MFTI NNOI. 1.BARE STEEL <br /> UI(NOWN ❑Z. STAINLESS STEEL ❑7 GALVANIZED STEEL <br /> ❑7.GALVANIZED STEEL ❑ > B FLEXIBLE(I IDPE.) ❑9S �'H! <br /> 099 OTHER <br /> ,' S1'.CGti' AER [:13. PLASTIC COMPATIBLE WICONTEN.S <br /> 3 'LA1'0'_E VV/CONTENTS Q <br /> ti 0 4. FIBERGLASS C30 CA'H00!C PRO'EC i 10" <br /> I [�a FLCRGLAI:S ❑6.fLEXIBLE0 <br /> (HOPE) 95 UNKNOWN <br /> C]9.CATilOD(C PRO tECTION <br /> 451 ❑5. STEELWICOATING <br /> PIPING LEAK DETECTION¢Iwick:dl ural auMY1 TPf InnHan Lonny proarom=11311 Da Suunvued w Lha local a(wncy) <br /> ABOVEGROUND PIPING <br /> 4SINGt E WALL PIPINGSINGLE WALL PIPINGSSURIZED PIPING(Chcck oa Lh01 JPPIY). <br /> PGrzE`:SURIZEDP:"ING(ChatA11131Wdr): THAUTOPUMPI EL rC'RONIC I INE LEAK DETECTOR 3.0 Gf H TESST yL AUTO PUMP SHUT OFF F . ELECTRONIC UNE LEAK DETECTOR 3I GPM TEST <br /> c STEM FAA URE.ANO SYS I EM DISCONNECTION+AUDIBLE AND VISUAL LEAK SYSTEM FAILURE,AND SYSI EM DISGONN[CTION+ AUDIBLE N,D V SJ;,L <br /> . !.K $Y. ALARMS. <br /> NARNC ❑2. MONTI ILY O.Z GPI I TEST <br /> G-e MCN I i _Y C 2 GPI!TEST <br /> ❑3. ANNUAL INTEGRITY TEST(O.1Gf N) <br /> r-13 ANI:',A,u,'EC2'IYTEST(0.1GPH) 04. DAILY VISUALCIIECK <br /> CONVENTIONAL SUCTION SYSTEMS(Char,all 0,4-011 <br /> ;�•; �',�y.,.SJC'IONSYSILMS DAILY VISUAL MONITORING OF PIPING AND PUMPINGSYSTEM <br /> D, • V S JAI.MONITORING,OF PUMPING SYSTEM+I RIENNIAL PIPING INTECRITY C]5. <br /> [36, TRICNNIAL INTEGRITY TEST(0.1 GPH) <br /> i StE SOC'UN SYS,I.M$. (NO VALUES IN ALLOW GIIOUNOPINING) <br /> d <br /> SAFE SUCTION SYSI EMS(NO VALVES IN BELOW GROUND PINI1tG) 1 <br /> G7 ;I'I .011ilOFiNG <br /> ❑1. SELF MONITORING <br /> GR 'r Y FL?W CRAVI')Y FLOW(Chock Of mil MOO <br /> I, ❑S n,EN'ill.L I,NTE'vIPY TES((0.1 LPH) I]0, DAILY VISUAL MONITORING <br /> ❑9. BIENNIAL INTEGRITY TEST(0.1 GPH) <br /> SSECONDARILY CONTAINED PIPING <br /> SECONDARILY CONTAINED PIPING <br /> PRLS$URIZED PIPING(Check all ural ePPIY): <br /> �r;I1S SLP�1717D PIPING(Check as that OnpIY)' <br /> ,VuOUS TURBINE SUM(SENSOR WITIJ AUDIBLE AND VISUAL ALARMS AND 10. CONTINUOUS TURBINE SUMP SENSOR WITH AUDi5LE AND V 0 UAL ALARMS ;'40 <br /> (Chock onc) <br /> J r„c.w) [:1 a AUTO PUMP SHUT OFF WHLN A LEAK OCCURS <br /> [� AJ f0 PUMP SI IUT OFF WHEN A LE:AI(p000R$ <br /> ❑C 1JTO PUMP SHUT OIT FOR LEAKS,SYSTEM FAILURE AND SYSTEM DISC❑A PUMP SHUT OFF FOR LEAKS,SYSTEM FNLLIRE A'0:Y`--PEM <br /> DISCONNECTION I <br /> DISCUNNCCNON ❑c NO AUTO PUMP SHUT OrF <br /> ❑r. HO AUTO PUMP SHUT OFF <br /> �v ( � .0 GPM TESTS wlT}(FLOw SHUTOFF OR ❑ <br /> 11. AUTOMATIC LEAK DETECTOR <br /> .1 AJTO.Y.ATIC UN' L.f.AK DE TECTOR p <br /> Y of T vC TION C312 ANNUAL INT EGRITY TEST(0.1 GPH) <br /> (� o\j ' NN-JAL 1'aIECRRY TCST(01 GPM <br /> \L 2 ASUCTIOWGMVRY SYSTEM <br /> �O ; c„C-O'yr,-,wit Y SYSTEM 0 13. CONTINUOUS SUMP SENSOR•AUDIBLE ANU VISUAL ALARMS <br /> '_(6T0,JCOSSUMP SENSOR-AUDIBLE AND VISUALALARMS <br /> EMERGENCY GENERATORS ONLY(Cnaek eu u1,r1 apply) <br /> EMERGENCY GENERATORS ONLY(CROCK hjk a=ril <br /> o c ITH ATO TUM('SHUT OFF AND ❑14 CONTINUOUS SUMP SENSOR VJITF)r1�AUT0 PUMr'SHUT OFF.AGC'F_= <br /> ❑14 C f:JOUS SUMP SFNSOI1yL�(V.( U VISUALAL.ARMS <br /> v SILA',N ARMS I <br /> III, ;.JTONA .0 LiNf_L fnK oETGCroR(3.0 GPM TEST)W TLQVI FLOW SI ILrT OFF OR ❑15. AUTOMATIC UNE LEAK DETECTOR(3.0 GPM TEST) <br /> RE STIII Cl ION ❑16. ANNUAL INTEGRITY TEST(0.1 GPH) <br /> ❑ .5 r TnJAL I'+'EGITTIY TEST(0.1 GPH) ❑17• DAILY VISUAL CHECK , <br /> i r-j 17 'C,VLY VIL'AL C'1ECK <br /> VIII.DISPENSER CONTAINMENT <br /> _ ❑ ON <br /> 4 LY VISUAL C'HCCK <br /> ~pi$I'ENjI I t CONI AINMENI (�1 FLOAT MECHANISM I I W SHUTS <br /> ­-PS-Off-SHEAR SNIEARVALVE ❑S.TRENCH LINER I MON T ORING <br /> DATE iNSTA'-LED wo 02. CONTINUOUS DISPENSER PAN SENSOR AUDIBLE AND VISUAL ALARMS �. <br /> 6.TIONS <br /> 03. CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR DISP[NSER+ <br /> [� <br /> AUDIBLE AND VISUAL N,ARM$ <br /> -• IX.OWNERIOPERATOR SIGNATURE <br /> -i Co.;Ir �' a a(myr�:,cn prov Ora Hurd,la lruo and L, I-to ale 0os17(my Itnowk:dye. OAl'E .11 <br /> SIGNiifI1R�'`�NGIZ/ .- TOR �- ... ..'7- Z'dVl <br /> /1 w TITLE OF OWNER/OPERATOR <br /> N Mr.`.Ur'OV�NERrOPI2ATOR(print) f7iroclor of Environmental Affairs <br /> M,ke Karvelot, for Quik Stop Markets, Inc. crrnlnpprovcd(For IO al u..t oMy) Perml up,fation Dila(For Ioc..•:sc <br /> Ir <br /> p,.ya5:Nr..^.ulr;rcOr ioc:rl u,o Only) <br /> 4!3 175 <br /> Formerly S`.NRi.(3 Fenn <br /> UPCI= (ilS9 revised) • ._ /D /6 pI <br />