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E UNUND PROGRAM CONSOLIDATED FORM -z' l G� TANKS UNDERGROUND STORAGE TANKS- TANK IT. - ) .W-1 ' Pae of �. VL PIPING CONSTRUCTION(deck all that a ) ` UNDERGROUND PIPING ABOVEGROUND PIPING SYSTEM T!PE ®1.PRESSURE ❑2.SUCTION: ❑3.GRAVITY 458. ❑).PRESSURE [12.SUCT10fN ❑3.GRAVITY 459. CONSTRUCTION/ [:11.SINGLE WALL ❑3.LINED TRENCH ❑99.OTHER 460. ❑L SINGLE WALL 0 95.UNKNOWN 462. MANUFACTURER 912.DOUBLE WALL. 1195.UNKNOWN 0 2.DOUBLE WALL ❑99.OTHER MANUFACTURER S'rY t 461. MANUFACTURER 463. ❑1.BARE STEEL ❑6.FRP COMPATIBLE W1100%METHANOL ❑1.BARE STEEL ©6.FRP COMPATIBLE W11 0(r/-METHANOL ©2.STAINLESS STEEL ❑7.GALVANIZED STEEL ❑2.STAINLESS STEEL 0 7.GALVANIZED STEEL '� ❑3.PLASTIC COMPATIBLE WITIi CONTENTS ❑95.UNKNOWN ❑3.PLASTIC COMPATIBLE W/CONTENTS ❑8.FLEXIBLE(HDPE) [3 99.OTHER 4.FIBERGLASS [18.FLEXIBLE(HDPE) [199.OTHER ❑4-FIBERGLASS ❑9.CATHODIC PROTECTION p 5.STEEL w1COATING 0 9.CATHODIC PROTECTION 464. ❑5.STEEL WICOATING ❑95.UNMOWN 465 VIL PIPING LEAK DETECTION-(Check all that )(A - -on ofine mondorug progmm shall be submitted to the Bowl agcuy.) UNDERGROUND PIPING ABOVEGROUND PIPING SINGLE WALL PIPING 466. SINGLE WALL PIPING �7 PRESSURI7ZI)PIPING(Cbec1 all that apply): PRESSURIZED PIPING(Check all that apply): ❑1. ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WPI AUTO PUMP ❑I. ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WTTH AUTOPUMP SHUT-OFF FOR LEAK,SYSTEM FAILURE,AND SYSTEM DISCONNECTION SFU-r OFF FOR LEAK,SYSTEM FAILURE,AND SYSTEM DISCONNECTION +AUDIBLE AND VISUAL ALARMS. +AUDIBLE AND VISUAL ALARMS, 02. MONTHLY 0.2 GPH TEST ❑2. MONTHLY 0.2 GPH TEST i [33- ANNUAL WTEGRTTY TEST(0.1 GPH) [13, ANiv'Li AL I1vTEGRiiY TEST(0.1 GPH) I 1..1 4. tDAILY'TSUAL CHECK CONNTN'ITONAL SUCTION SYSTEMS CONVENTIONAL SUCTION SYSTEMS(Chcok all that apply) ❑5. DAILY VISUAL MONITORING OF PUMPING SYSTEM+TRTENNIAL PIPING []5. DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM INTEGRTTY TEST(0.1 GPH) SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): ❑6. TRIENNIAL INTEGRITY TEST(0.1 GPH) ❑7. SFLF'.4ONITORING SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): GRAVITY FLOW ❑7. SEF MONITORING ❑9. BIENNIAL INTEGRITY TEST(0.1 GPM GRAVITY FLOW(Check all that apply): ❑8. DAILY VISUAL MONITORING [39. BIENNIAL INTEGRITY TEST(0.3 GPH) SECON,DAMLY COWTAINED PIPING SECONDARILY CONTAINED PIPING PRESSURIZED PIPING(CbML'211 that apply): PkESSURIZF•D PIPING(Check all that apply): 10. CONTINUOUS TURBTNE SUMP SENSOR AUDIBLE AND VISUAL 10. CONTINUOUS TURB[NE SUMP SENSOR V,1 AUDIBLE AND VISUAL ALARMS AND(Check one) ALARMS AND(Check one) ❑2- AUTO PUMP SHUT OFF WHEN A LEAK OCCLMS �a. AUTO PUMP SHUT OFF WHENA LEAK OCCURS I ®6.AUTO PUMP SHUT-OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM ®b.AUTO PUMP SIiUT OFF FOR LEAKS,SYSTEM FAIUJRE AND SYSTEM DISCONNECTION DISCONNECTION ❑c. NO AUTO PUMP SHUT OFF ❑c. NO AUTO PUMP Sli[TT OFF Eiji. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)WITH FLOW SHUT 49 11.AUTOMATIC LEAK DETECTOR OFF OR RESTRICTION 0 12. ANNUAL INTEGRITY TEST(0.1 GPI ❑12. ANNUAL INTI CiRITY TEST(0.1 GPM SUCTIOWGRAVTTY SYSTEM SUC-nO,NfGRAVTTY SYSTEM I (113. CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS ❑13. CONTINUOUS SUMP SENSOR+AUDU3LE AND VISUAL ALARMS I EpS£RGENCY GENTiRATORS ONLY(Cheri all that apply) EMERGENCY GENERATORS ONLI'(Chac1:all that 2MY) (J14. CONTINUOUS SUN]'SENSOR WTTHOLU AUTO PUMP SHUT OFF ❑ CONTINUOUS SUMP SENSOR AUTO PUMP ST3UT OFF 14" AUDIBLE AND VISUAL ALARMS WITHOUT AUDIBLE AND VISUAL ALARMS 15. AUTOMATIC LINE LEAK DETECTOR (3.0 GPH TEST) WITH FLOW ❑15- AUTOMATIC LINE LEAK DETECTOR(3.0 GPIs TEST) i SHUT OFF OR RESTRICTION ❑16. ANNUAL INTEGRITY TEST(0A GPH) ❑16. ANNUAL INTEGRITY TEST(0.1 GPM ❑17.DAILY VISUAL C.7iECK ❑17. DAILY VISUAL CHECK VIIL DISPENSER CONTAINMENT k DISPENSER CONTAIT�NIENT 468. Ell. FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE ❑4. DAILY VISUAL CHECK - DATE INSTALLED ®2. CONTINUOUS DISPENSER PAN SENSOR+AUDIBLE AND VISUAL ALARMS ❑5. TRF ER MOMTOAING I 3. CONTINUOUS DISPENSER PAN SENSOR � AUTO SHUT OFF FOR [36. N� Q DISPENSER t-AUD113L.E AND VISUAL ALARMS UC OWNERlOPERATOR SIGNATURE I tfy tha the info tion provided herein is true and accurate to the hest of my knowledge. 470. 4- SIGNATURE OF OWNER/OPERATOR r - ` D" C) 472. N OF OWNERIOPI RAZOR(grin[}: CO-'%-f rut" D`"' TITLE OF OWNERIOPERATOR at>_cr) CA b` 473. Perritit Approved By(Agency use only) 474. Permit Expiration Date(AgeacY ttse Only) 475. Permit Number(Agency e only) J '