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U ED PROGRAM CONSOLIDATED FORM TANKS UNDERGROUND STORAGE TANKS-TANK PAGE 2 Page of Yl.PIPING CONSTRUCTION Chock all that UNDERGROUND PIPING ABOVEGROUND PIPING SYSTEM TYPE 1.PRESSURE ❑2.SUCTION ❑3.GRAVITY 458. ❑I.PRESSURE [12-SUCTION ❑3.GRAVITY 459. CONSTRUCTION/ ❑I.SINGLE WALL ❑3.LINED TRENCH [:199.OTHER 460. ❑L SINGLE WALL ❑95.UNKNOWN 462 MANUFACTURER AC z DOUBLE WALL ❑95.UNKNOWN ❑2_DOUBLE WALL ❑99.OTHER MANUFACTURFI( t Qr Sfr�I� 461- MANUFACTURER 463 ❑1.HARE STEEL ❑6.FRP COMPATIBLE W/IOtP/METHANOL ❑I.RARE STEEL ❑6.FRP COMPATIBLE W/l OW METHANOL ❑2.STAINLFSS STEFL ❑7.GAINANI7RD STEEL []2.STAINLESS MEL ❑7.GALVANIZED STEEL -ASTIC COMPATIBLE WITH CONTFNT5 ❑95(UNKNOWN ❑3.PLASTIC COMPATIBLE W/CONTENTS ❑8.FLEXIBLE(HDPE) ❑99.OTHER 4.FIBERGLASS ❑R-FLEXIBLE(HDPF) ❑99-OTHER ❑4.F1BfRG1.ASS ❑9.CATHODIC PROTECTION ❑5.STEEL W/COATING ❑9.CATHODIC PROTECTION A(A. ❑S.STEEL WICOATING ❑95.UNKNOWN 465- V IL PIPING LEAK DETECTION IChcck all thin )(A iption o f the nwiloring pmgrwn shall be wbtniued to the local a y I/NDFRGROUND PIPING ABOVEGROUND PIPING SINGLE WALL.PIPING 461, SINGLE WALL PIPING 467. 7PR UWXD XD PIPING(Check all that apply): PRESSURIZED PIPING(Check all that apply): �) SELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AT PUMP ❑I. FLFCTRONIC LINE LEAK DF.TECTOR 3D GPH TFST WITH AUTO PUMP SHUT-OFF FOR LEAK-SYSTEM FA1I.URF.,AND SYSTEM DISCONNECTION SHUTOFF FOR LEAK,SYSTEM FAILURE„AND SYSTEM DISCONNECTION +AUDIBLE AND VISUAL ALARMS. +AUDIBLY AND VISUAL ALARMS. ❑2. MONTHLY 0.2 GPU TEST [12. MONTHLY 0.2 GPH TEST [13. ANM)At,INTEGRITY TEST(O.l OPH) ❑3. ANNUAL.INTEGRITY TEST(D.1('1PE) 04. DAILY VIS(1ALCHECK CONVENTIONAL SUCTION SYSTEMS CONVENTIONAL SUCTION SYSTEMS(Check all that apply) ❑5. DAILY VISUAL MONITORING OF PUMPING SYSTEM+TRIENNIAL PIPING L]5. DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM INTEGRITY TEST(0-1 GPH) SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): [16. TRIENNIAL[NTECIUTY TL•Sf(o.i GPIi) ❑7- SELF MONITORING SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): GRAVITY FLOW [17. SELF MONITORING ❑9. BIENNIAL INTEGRITY TEST(0.1 GPH) GRAVITY FI.O'*V(Check all that apply): ❑8. DAILY VISUAL.MONITORING []9- BIENNIAL INTEGRITY TEST(0.1(iPI?) SECONDARILY CONTAINED PIPING SECONDARILY CONTAINED PIPING , PRESSURIYED PIPING(Check ail that apply): PRESSURIZED PIPING(Check al I tlmt apply). 10. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL 10. CONTINUOIJS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL ALARMS AND(Check one) At ARMS AND(Check one) a_AUTO PUMP SHUT OFF WHEN A LEAK OCCURS ❑a.AUTO PUMP SITUT OFF WHEN A LEAK OCCURS V.AUTO PUMP SITUT OFF FOR(YAKS,SYSTEM FAILURE AND SYSTEM ❑b.AUTO PUMP SHUT OIT FOR LEAKS,SYSTEM FAILURE AND SYSTEM DISCONNECTION DISCONNF.Cr10N ❑c. NO AU CO PUMP SNIT OIT ❑c. NO AI1TO PUMP SHUT OFF 11. AUTOMATIC LINE LEAK DETECTOR(3-0 GPH TEST)WITH FLOW SHUT ❑11,AUTOMATIC LEAK DETECTOR lllJJT��''' OFF OR RESTRICTION ❑17. ANNUAL INTEGRITY TEST(0.1 GPH) ppJ K90u)jq ❑12.ANNUAL INTEGRITY TEST(0.I GPIs) SUCTION/GRAVITY SYSTEM SUCTIONIGRAVITY SYSTEM ❑13. CONTINJOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS ❑11. CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS EMERGENCY GENERATORS ONLY(Cbeck all then apply) FMER(:F,NCY GENERATORS ONLY(Check all theft apply) ❑14. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT(IFF ❑14. CONTINIJOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF AUDIBLE AND VISUAL.ALARMS AUDIBLE AND VISUAL ALARMS ❑15. AlITOMAT1C JJNF, LEAK DETECTOR (3.0 GPH TEST) WITHOUT FLAW ❑15.AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST) SHUTOFF OR RESTRICTION ❑16. ANNUAL INTEGRITY TEST(0-1 GPH) ❑16 ANNUAL INTEGRITY TEST(0.1 GPH) 017, DAILY VISUALCILEAK ❑37. DAILY VISUAL CHECK VIII.DISPENSER CONTAINMENT DISPENSER CONTAINMENT 468. L11. FLOAT MECHANISM'1'IIAr SHUTS OFF SHEAR VALVE �111LYVIUAL CEIECK 469. DATE INSTALLED A ❑2. CONTINUOUS DISPENSER PAN SENSOR+AUDIBLE AND VISUAL ALARMS ❑5. TRENCH/LINER MONITORING ❑3. CONTINUOUS DISPENSER PAN SENSOR WITE AUTO SUNT OFF FOR 6 NONE DISI'FNSER t AUDIBLE AND VISUAL ALARMS IJ(.OWNERIOPERATOR SIGNATURE I cert the infjpnafion provide4hercin is true an accurate m the hest of my knowledge- . iOPERAT 61iy� D azo. Y 7,777 472. NAME OF (Tt PFIRATORt{pJinti: TITI F OF OWNERIOPERA �tT'V1 re OR: Permit Number(Agency face only) 473. Permit Approved By(Agency use only) 474 1 Permit Expiration Date(Agency ice only) 475. UPCF hwfwre-h(1199)-3/4 bttp-//www.unIdoeLarg Rev.02/16/00