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TANKS <br /> UNDERGROUND STORAGE TANKS-TANK PAGE 2 <br /> Pa&S. of <br /> VT.PIPING CONSTRUCTIO all that apply) <br /> UNDERGROUND PIPING ABOVEGROUND PIPING <br /> SYSTEM TYPE K1.PRESSURE [12.SUCTION ❑3.GRAVITY 458. 0 1.PRESSURE 0 2.SUCTION [I 3.3RAVITY 459. <br /> CONSTRUCTION/ rl 1.SINGLE WALL C3 3.LINED TRENCH ❑99.OTHER 460. []I.SINGLE WALL [3 95.UNKNOWN 462. <br /> MANUFACTURER JZ2Cj 2.DOUBLE WALL [199.OTH FR.DOUBLE WALL 0 95.UNKNOWN - <br /> MANUFACTURER 461. MANUFACTURER 463. <br /> 0 1.BARE STEEL n 6.FRP COMPATIBLE W/100%METHANOL 0 1.BARE STEEL 0 6.FRP COMPATIBLE W/100%METHANOL <br /> 0 2.STAINLESS STEEL []7.GALVANIZED STEEL n 2.STAINLESS STEEL 0 7.GALVANIZED STEEL <br /> 0 3.PLASTIC COMPATIBLE WITH CONTENTS 0 95.UNKNOWN M 3.PLASTIC COMPATIBLE W/CONTENTS 0 8.FLEXIBLE(III)PIcEI) ❑99.OTHER <br /> �Q.FIBERGLASS 0 8.FLEXIBLE(HDPE) 0 99,OTHER [3 4.FIBERGLASS [19.CATHODIC PROTECTION <br /> 0 S.STEEL W/COATING [19.CATHODIC PROTECTION 464. [3 5.STEEL W/COATING [195.UNKNOWN 465. <br /> V11.PIPING LEAK DETECTION(Check all that apply)(A descrilmon of the monitoring program shall be submitted to the local agency.) <br /> SINGLE WALL PIPING UNDERGROUND PIPING 466. SINGLE WALL PIPING ABOVEGROUND PIPING <br /> 467. <br /> PRESSURIZED PIPING(Check all that apply): PRESSURIZED PIPING(Check all that apply): <br /> ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP []L ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP <br /> SHUT-OFF FOR LEAK,SYSTEM FAILURE,AND SYSTEM DISCONNECTION SHUT OFF FOR LEAK,SYSTEM FAILURE,AND SYSTEM DISCONNECTION <br /> +AUDIBLE AND VISUAL ALARMS. +AUDIBLE AND VISUAL ALARMS. <br /> [32. MONTHLY 0.2 GPH TEST [12. MONTHLY 0.2 GPH TEST <br /> 0 3. ANNUAL INTEGRITY TEST(0.1 GPH) 03. ANNUAL INTEGRITY TEST(0.1 GPH) <br /> [I 4. DAILY VISUAL CHECK <br /> CONVENTIONAL SUCTION SYSTEMS CONVENTIONAL SUCTION SYSTEMS(Check all that apply) <br /> 0 5. DAILY VISUAL MONITORING OF PUMPING SYSTEM+TRIENNIAL PIPING 0 5. DAILY VISUAL MONITORING OF PIPING AND PUlk,IPING SYSTEM <br /> INTEGRITY TEST(0.1 GPH) <br /> SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): []6. TRIENNIAL INTEGRITY TEST(0.1 GPH) <br /> [3 7. SELF MONITORING SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): <br /> GRAVITY FLOW [17. SELF MONITORING <br /> 09. BIENNIAL INTEGRITY TEST(0.1 GPH) GRAVITY FLOW(Check all that apply): <br /> 0 S. DAILY VISUAL MONITORING <br /> [-]9. BIENNIAL INTEGRITY TEST(0.1 GPH) <br /> SECONDARILY CONTAINED PIPING SECONDARILY CONTAINED PIPING <br /> PRESSURIZED PIPING(Check all that apply): PRESSURIZED PIPING(Check all that apply): <br /> 10. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL to. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL <br /> ALARMS AND(Check one) ALARMS AND(Check one) <br /> P,a.AUTO PUMP SHUT OFF WHEN A LEAK OCCURS [3 a.AUTO PUMP SHUT OFF WHEN A LEAK OCCURS <br /> 0(b.AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM C3 b.AUTO PUMP SHUT OFF FOR LEAKS,SYSTE4 FAILURE AND SYSTEM <br /> DISCONNECTION DISCONNECTION <br /> [1c. NO AUTO PUMP SHUT OFF r1c. NO AUTO PUMP SHUT OFF <br /> I- AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)WITH FLOW SHUT ❑11.AUTOMATIC LEAK DETECTOR <br /> OFF OR RESTRICTION <br /> 0 12. ANNUAL INTEGRITY TEST(0.1 GPH) 0 12. ANNUAL INTEGRITY TEST(0.1 GPH) <br /> SUCTION/GRAVITY SYSTEM SUCTION/GRAVITY SYSTEM <br /> [:]13. CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS []13.CONTINUOUS SUMP SENSOR+AUDIBLE AND VI SUAL ALARMS <br /> EMERGENCY GENERATORS ONLY(Check all that apply) EMERGENCY GENERATORS ONLY(Check all that apply) <br /> C]14. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF 0 14.CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF <br /> AUDIBLE AND VISUAL ALARMS AUDIBLE AND VISUAL ALARMS <br /> 0 15. AUTOMATIC LINE LEAK DETECTOR (3.0 GPH TEST) WITHOUT FLOW 15.AUTOMATIC LINE LEAK DETECTOR(3.0 GPH Ti IST) <br /> SHUT OFF OR RESTRICTION <br /> 016. ANNUAL INTEGRITY TEST(0.1 GPH) El 16. ANNUAL INTEGRITY TEST(0.1 GPH) <br /> [117. DAILY VISUAL CHECK ❑17.DAILY VISUAL CHECK <br /> VIII.DISPENSER CONTAINMENT <br /> DISPENSER CONTAINMENT 468, 1. FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE ❑4. DAILY VISUAL CHECK 469. <br /> DATE INSTALLED [32. CONTINUOUS DISPENSER PAN SENSOR+AUDIBLE AND VISUAL ALARMS 05. TRENCII/LNER MONITORING <br /> C13. CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR n 6. NONE <br /> DISPENSER+AUDIBLE AND VISUAL ALARMS <br /> IX.OWNER/OPERATOR SIGNATURE <br /> I certify thoe information provided h is true and accurate to the best of my knowledge. 470. <br /> SIGNATU E F OWNER/IlffIOR DATE: -7 <br /> C <br /> NAME OF AIJ�OPEtRa(O�R472. <br /> �Print): TITLE OF OWNER/OPERATOR: <br /> Permit Number(Agency use only) 473. Permit Approved By(Agency use only) 474. 1 Permit Expiration Date(Agency use only) 475. <br /> UPCF hwfwre-b(1/99)-314 http://www.unidocs.org Rev.02/16/00 <br />