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` TTNTI+, ,n PRO(-R AM C0N.g0T.T"ATF.iI-FORM "O `,� 9 TANKS �� UNDERGROUND STORAGE TANKS - TANK PAGE 2 Pae of VI.PIPING CONSTRUCTION(Check all that a ly) ABOVEGROUND PIPING UNDERGROUND PIPING a59. SYSTEM TYPE i.PRESSURE ❑2.SUCTION ❑3.GRAVITY 458. ❑1.PRESSURE ❑2.SUCTION ❑3.GRAVITY WN a6z. CONSTRUCTION/ ❑1.SINGLE WALL ❑3.LINED TRENCH ❑99.OTHER 460. ❑1.SINGLE WALL ❑9999.O5. THER MANUFACTURER ❑2.DOUBLE WALL ❑ I.Z.DOUBLE WALL ❑95.UNKNOWN 461. MANUFACTURER 463. MANUFACTURER [36.FRP COMPATIBLE W/100%METHANOL ❑1.BARE STEEL ❑6.FRP COMPATIBLE W/100%METHANOL ❑1.BARE STEEL 7 GALVANIZED STEEL ❑2.STAINLESS STEEL [17.GALVANIZED STEEL C12.STAINLESS STEEL ❑ ❑3.PLASTIC COMPATIBLE WITH CONTENTS [395.UNKNOWN ❑3.PLASTIC COMPATIBLE W/CONTENTS ❑❑9.FLEXIBLE(HDPE) PR99.OTHER PROTECTION ❑ 4.FIBERGLASS [18.FLEXIBLE(HDPE) ❑99.OTHER ❑4.FIBERGLASS ❑95.Lti'IG`OWN 465. 464. [15.STEEL W/COATING ❑5.STEEL W/COATING ❑9.CATHODIC PROTECTIONB shall submitted to the bdY) VII.PIPING LEAK DETECTION(Check all thatapply)(A descn ion of the monitoring Pro pgOVEGROUND PIPING UNDERGROUND PIPING a67. 466. SINGLE WALL PIPING SINGLE WALL PIPING PRESSURIZED PIPING(Check all that apply): PRESSURIZED PIPING(Check all that apply): 3.0 GPH TEST WITH AUTO PUMP ❑1. ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO P UMP 1. ELECTRONIC LINE LEAK DETECTOR AND SYSTEM DISCONNECTION S`ANUfD BE AND VISUAL AL TEM F ALARMS. AND SYSTEM DISCONNECTION SHUT-OFF FOR LEAK,SYSTEM FAILURE, +AUDIBLE AND VISUAL ALARMS. ❑2. MONTHLY 0.2 GPH TEST ❑2. MONTHLY 0.2 GPH TEST ❑3. ANNUAL INTEGRITY TEST(0.1 GPH) �3. ANNUAL INTEGRITY TEST(O.l GPH) [14. DAILY VISUAL CHECK CONVENTIONAL SUCTION SYSTEMS(Check all that apply) CONVENTIONAL SUCTION SYSTEMS ❑5. DAILY VISUAL MONITORING OF PUMPING SYSTEM+TRIENNIAL PIPING [15. DAILY VISUAL MONITORING OF PIPING AN'D PUMPING SYSTEM INTEGRITY TEST(0.1 GPH) ❑6. TRIENNIAL INTEGRITY TEST(0.1 GPH) SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): [17. SELF MONITORING [17. SELF MONITORING GRAVITY FLOW GRAVITY FLOW(Check all that apply): [19. BIENNIAL INTEGRITY TEST(0.1 GPH) ❑g DAILY VISUAL MONITORING C]9. 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 AND(Check one)SUMP SENSOR WITH AUDIBLE AND VISUAL ALARMS AND(Check one) ❑a. AUTO PUMP SHUT OFF WHEN A LEAK OCCURS AUTO PUMP SHUT OFF WHEN A LEAK OCCURS . AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM ❑b T OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM DISCONNECTION DISCONNECTION [1c. NO AUTO PUMP SHUT OFF ❑c. NO AUTO PUMP SHUT OFF 11. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)WITH FLOW SOk HUT ❑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 l3.CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARM ❑13. CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS EMERGENCY GENERATORS ONLY(Check all that apply) EMERGENCY GENERATORS ONLY(Check all that apply) []14. CONTINUOUS SUMP SENSOR WIT AUTO PUMP SHUT OFF ❑14.AUDIBLE LO�S�UA VISUAL AUTO PUMP SHUT OFF AUDIBLE AND VISUAL ALARMS ❑15. AUTOMATIC LINE LEAK DETECTOR (3.0 GPH TEST) WITHOUT FLOW ❑15. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST) SHUT OFF OR RESTRICTION ❑16. ANNUAL INTEGRITY TEST(0.1 GPH) ❑16. ANNUAL INTEGRITY TEST(0.1 GPH) ❑17.DAILY VISUAL CHECK ❑17. DAILY VISUAL CHECK VIII.DISPENSER CONTAINMENT 4. DAILY VISUAL CHECK 469. DISPENSER CONTAINMENT 468. ❑1. FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE DATE INSTALLED [32. CONTINUOUS DISPENSER PAN SENSOR+AUDIBLE AND VISUAL ALARMS C]5. TRENCH/LINER MONITORING ' 3. CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR ❑6. NONE C 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. 470. SIGNA R , -OWNER/OPERATOR DATE: � - 472. TITLE OF OWNER/OPERATOR: NAME OF OWNER/OPE ATOR print): p � 473. 1 Permit Approved By(Agency use only) 474. 1 Permit Expiration Date(Agency use only) 475 Permit Number(Agency use only) . UPCF hwfwrc-b(1/99)-3/4 http://www.unidocs.org Rev.02/16/00