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FEB-07-2001 WED 03:44 PM QUIK STOP MKTS INC FAX NO. 51065/1544 N. U5 UNIFIED PROGRAM CONSOLIDATED FORM TANK UNDERGROUND STORAGE TANKS - TANK PAGE 2 Vow_of VI.PIPING CONSTRUCTION(ChccA all Ilial apply) -�" UNDEkGROUND PIPING ABOVEGROUND PIPING SYSTEM TYPE 1.pRESGURE ❑2.SUCTION 3,GRAVITY Asa ❑1,PRESSURE Q 2. 6UC(ION ❑3,GRPVITY 4UA CONST RUCTION I Q 1.SINOL(WAIL Q 3.UNED RRENCH� Q 9o.Ol l lCR A60 1.SINGLE WALL ❑99.OTI95. I ICRC 412 MANUFACTURER 0 2.DODUI F.WALL Q 95.UNKNOWN []2.DOUDLE WALL Q 46� MANUFACTURERS Aha MANUFACTURER AQ Smith 1,DARE STEEL Q 6.FHP COMPATIBLE W1100%METIW1Ol FCOJI'3, ""L 6.FRP COMPAlSTE a/7WY. M([I UX ❑ o 7 GALVANIZED STEEL LESS STEEL p 7,GALVANIZED STEEL Q UKNOWN ❑2, �TAINLEoS STEEL ❑ IC COMPATIOLE WI CON TENTS ❑99. OTHER ❑3. PLASTIC COMPATIBLE WP CONTENTS ❑8.FLEXIBLE(I IDPE) ❑99, OTHER GLASS O 6.FLEwBLE(hIDPE) FIBERGLASS ❑9,CATHODIC PROTECTION LwPCOAI'ING Q 9.CATLIODIC PROTECTION A64 Q 5. 51t[LWICOATING ❑95.UNKNOWN 405 aubrTfMM to 1110 loq4l "Viii.PIPING LEAK DETECTION(Uhai woiu aaooty)(AdescdpLjonorI1ienwnllolln roCrams4aIbOVE3R0UNP PIPINU n`Y) r" UNDERGROUND PIPING 46G SINGLE ALL PIPING 4G7 SIS NGLE WALL PIPING PRCSSURIZEU I'(f TNG(Chrck o1 u+at spphk PRESSURIZED PIPING(Check all that apply): 0i, 1 I EAK SYS�CM FAILURE,ANO SYSTEM 0 GONNCCI'ION HAUDIOLEUAND VISUO`F FOR Q 1 LEAK,SYSTEM FAILURE,LECTRONIC LINE AN SYSTEM DISCONNECTION t AUDIBLE AND VISUAL F FOR N ARMS ALARMS, ❑2. MONTHLY 0,2 GPH TEST ❑2, MON71 ILY 0.2 GPH T EST ❑3, ANNUAL INTEGRITY T6ST(0.1CPI I) E13, ANNUAL INTEGRITY TEST(0.1GPH) C14. DAILY VISUAL Cl IECK CONVENTIONAL.SUCTION SYSTEMS CONVENTIONAL SUC(IoN SYSTEMS(Chcck al that apply) Q5. DAILY VISUAL MONITORING,Or PUMPING SYSTEM,TRIENNIAL PIPING INTEGRITY ❑5. DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM TEST(0.1 CPH) Q 6. TRICNNIAL INJ EGRITY TEST(0,1 GPH) SAFE SUCrI0N SYSTEMS(NOVALUES IN DFLOW GilOUNDPIPING)I Q 7. SELF MONI701'(1NG SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): ❑7, SELF MONITORING fY FLOW [39, BIENNIAL INTEGRITY TEST(0.1 GPH) GRAVITY FLOW(Clock�I 111-A apPIY)t CIlI, DAILYVISUALMONITORING [39. BIENNIAL INTEGRITY ZEST(0.1 GPH) SECONDARILY CONTAINED PIPING SECONDARILY CONTAINED PIPING PRESSURIZED PIPING(Check fill that oPply): PRESSURIZED PIPING(Check all Ihal opply): 10. CONTINUOUS TURD INE SUMP SENSDR WIT( AUDIBLE AND VISUAL ALARMS AND 10. ((0aka CONTINUOUS TURBINE SUMP SENSOR WITI jAUDIBLE AND VISUAL ALARMS AND (Chock Oft) Ca 3 AUTO PUMP SHUT OrF WHEN A LEAK OCCURS Q& AUTO PUMP SHUT OFF WHEN A LEAK OCCURS b AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM Rb. AUTO PUMPS)IUT OFF FOR LEAKS,SYSTEM rAILURE AND SYSTEM Q DISCONNECTION DISCONNECTION ❑c NO AUTO PUMP SHUT OFF [2c, NO AUTO PUMP SHUT OFF X11. AUTOMATIC LING LEAK L f�CTOR(3 0 GPH.TEST) LTL FLDW SI IU'fOFF OR ❑11, AUTOMATIC LEAK DETECTOR R173TRICT10N �f 'a� tc1(1 01 012. ANNUAL INTEGRI TY TEST(a.I GPH) [712. ANNUALINTEGILfYTEST(0. GPI SUCTION/GRAVITYSYSTCM SUC1IOWGRAVITY SYSTEM CONTINUOU3SUMP SENSOR+AUDIBLE AND VISUAL ALARMS ❑13. CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL AIARMS Q 13. EMERGENCY GENERATORS ONLY(Chock olt Out apply) EMERGENCY GENERATORS ONLY(Check all that apply) [714. CONT INUOUS SUMP SENSOR Ff H IIT AUTO PUMP SHUT OrF+AUDIBLE AND ❑14' VISUAL ALARMS SENSOR WNITHQ(j(AUTO PUMP SMUT OFF•AUOIDLE AND VISUAL ALARMS Q 15. AUTOMA)IC LINE LEAK Dr;TECTOR(3.0 GPH TEST)WI rHOUT FLOW SHUT OFF OR ❑15, AUTOMATIC LING LEAK DETECTOR(3.0 GPI I TEST) RESTRICTION 016. ANNUAL INTEGRITY TEST(0.1 GPH) []15. ANNUAL INTEGRITY 1T.ST(0.1 GPI I) []17, DAILY VISUAL CHECK 017. DAILY VISUAL Cl IECK VIII.DISPENSER CONTAINMENT DISPENSER CIDNTAINMENT;01. FLOAT MECHANISM THAT SFIU N OFF SHEARVALVL ❑4.DAILVISUAL G(CCK 5.TRENCH LINER I MONITORING DATE INSTALLED 460 [32. CONTINUOUS DISPENSER PAN SENSOR•AUDIDIEANDYISUALAIARMS M6 NONE 409 t@3. CONTINUOUS DISPENSER PAN SENSOR�AUTO SHUT OFF FOR DISPENSER+ AUDIBLE AND VISUAL ALARMS ----" IX.OWNERIOPERATOR SIGNATURE I c:anlly Thal mg Inlormoilon yiuy(deo horcin m true and acwrolc to mo boGl or my knowlod0c� _ - 470 2=rWTOR E iATOR OATS(print) TITLE OFOWNtR/OPERATOR 472 Mike I<arvelot, for Quik Stap Markets Inc. Director of F-nvironmental Affairs 473 eormit Approvod(For local use ady) Parml Explrallon Ualo(For 1oc31 USG only) PCliiyl NUmh':r Ira local USG,only) - 475 Formoriy SWROB Farm B UPCF (1199 revised)