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USIED PROGRAM CONSOLIDATED FORM TANKS UNDERGROUND STORAGE TANKS-TANK PAGE 2 Pa•r of Vi.PIPING CONSTRUCTION tawkn gait UNDERGROUND PIPING ABOVEGROUND PIPING SYSTEM TYPE 1.PRESSURE. ❑2.SUCTION ❑3.GRAVITY 458. [31.PRESSURE C12.SUCTION [13.GRAVITY 459. CONSTRUCTION/ ❑I.SINGLE WALL ❑3-LINED TRENCH ❑99.OTHER 4A ❑L SINGLE WALL ❑95.UNKNOWN 462 MANUFACTURER �2 DOUBLE WALL [195.UNKNOWN ❑2.DOUBLE WALL ❑99.OTHER MANUFACTURER '� -r'1 t 461_ MANUFACTURER 463. ❑1.HARE STEEL ❑6.IRP COMPATIBLE W/1101'/METHANOL ❑1,RARE STEEL ❑6.FRP COMPATIBLE W/)OD%METHANOL ❑2.STAINLESS STEEL ❑7.GAi.VANIZF.D STEEL Q 2.STAINLESS STr-FL ❑7.GALVANIZED STFEI. ❑3.PLASTIC COMPATiBi.F.WITH CONTENT'S ❑95.UNKNOWN ❑3.PLASTIC COMPATIBLE W/CONTENTS ❑8.FLEXIBLE(HDPE) ❑99-OTHER ❑4.FIBERGLASS ❑8-FLEXIBLE(HDPE) ❑99-OTHER ❑4.FIBERGLASS ❑9.CATHODIC PROTECTION ❑5.STEEL W/COATING ❑9.CATHODIC PROTECTION u(A. ❑5.STEEL W/COATING ❑95.UNKNOWN 46.5. VIL PIPING LEAK DETECTION Cheek all dwt (A itifion of the mmiloringpnigratusliall be s»ituittcd tothc kic+l army) UNDERGROUND PIPING ABOVEGROUND PIPING SINGLE WALL PIPING 466. SINGLE WALL PIPING 467. 7PREp45URIZED PIPING(Cbeek all that apply)- PRESSURIZED PIPING(Check-.,It thiel apply). 1. ELECTRONIC LINE LEAK DETECTOR 3.0 GPif T'FST WITH AUTO PUMP ❑L ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WiTH AUTO PUMP SITI/T-OFF FOR i.F.AK_SYSTEM FAiid1RE,AND SYSTEM DISCONNECTION SHUTOFF FOR LEAK,SYSTEM FAILURE,AND SYSTEM DISCONNECTION +AUDIBLE-AND VISUAL ALARMS. +AUDIBLE AND VISUAL ALARMS. ❑2. MONTITLY 0.2 GPH TEST [12. MONTHLY 02 GPH TEST ❑3. ANNUAL tNTFC*RITY TUST(0.1 OPH) ❑3. ANNUAL INTFAIR1TY TEST(01 OPH) ❑4 DAILY ViSUAL CHECK CONVE+NTIONAT.SUCTION SYSTEMS CONVENTIONAL SUCTION SYSTEMS(Check all that apply) ❑5. DAILY VISUAL MONITORING OF PUMPING SYSTEM+TRIENNIAL PIPiNG [35. 13AITY VISUAL MONITORING OF PIPING AND PUMPTNG SYSTEM TNTLGRiTY TEST(0.1 GPM) SAFE SUCTION SYSTEMS(NO VALVES IN BE LOW GROUND PIPING): C]6. TRIENNIAL INTEGRITY TEST(0.1 GPis) ❑7- SELF MONITORING SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): GRAVITY FLOW ❑7. SELF MONITORING ❑9. BIENNIAL INTEGRITY TEST(0.1 GPH) GRAVITY FLOW(Check all that apply): ❑8, DAILY VISUAL.MONITORING [19. BIENNIAL INTEGRITY TEST(0.1(iPII) SECONDARILY CONTAINED PIPING SECONDARILY CONTAINED PIPING PRESSURi7ED PIPING(Check all that apply): PRESSURiZED PIPING(Check all that apply): 10. CONTINUOUS TURBINE SUMP SENSOR WiTH AUDIBLE AND VISUAL. 10. CONTINUOUS TURIONE, SUMP SENSOR WITH AUDIBLE AND ViSUAL At. MS AND(Check one) At AND(Check one) V AUTO PUMP SHUT OFF WHEN A LEAK OCCURS ❑u. AUTO PUMP SHUT OFF WITEN A LEAK OCCURS ❑b.AUTO PUMP SITUT OFF FOR LEAKS,SYSTEM FAiI13RE AND SYSTEM ❑b.AUTO PUMP SHUT 01-T FOR LEAKS,SYSTEM FAILURE-AND SYSTEM DISCONNECTION DISCONNECTION ��❑c. NO AUTO PUMP S111JT'OFT ❑c, NO AUTO PUMP SIRIT OFF L,Y)1 AUTOMATTC LINE LEAK DETECTOR(3.0 GPIT TEST)WiTId FLOW SHUT ❑1).AUTOMATIC LEAK DETECTOR OFF OR RESTRICTION ❑12. ANNUAL INTEGRITY TEST(0.1 GPH) Q 12.ANNUAL INTEGRITY TEST(0A GPII) SUCTION/GRAVITY SYSTEM SUCTiON/GRAVITY SYSTEM [113. CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS ❑13. CONTINUOUS SUMP SENSOR+ADDIBLE AND VISUAL:ALARMS EMERGENCY GENERATORS ONLY(Check all than apply) EMERGENCY GFNF.RATORS ONLY(Check till that apply) [114. CONTINUOUS STUMP SENSOR WITHOUT AUTO PUMP SHUT OFF ❑14. CONTINUOUS SUMP SENSOR WiTHOUT AUTO PUMP SHUT OFF AUDIBLE AND VISUAL ALARMS AUDIBLE AND VISUAL ALARMS ❑15. AUTOMATIC LINE LEAK DETECTOR (3.0 GPH TEST) WITiTOUT FLAW D 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 DISPENSER CONTAINMENT 468. ❑L FLOAT MECHANISM THAI'SHUTS OFF SHEAR VALVE jX1. DAILY VISUAL CHECK 469. DATE INET LED []2. CONTINUOUS DISPENSER PAN SENSOR+AUDIBLE AND VISUAL ALARMS ❑5. TRENCH/LiNER MONITORING []3- CONTINUOUS DISPL"NSFR PAN SENSOR WITH i'AUTO SHUT OFF FOR P<- -'NONE DISI,FNSER+AUDIBLE ANDVISUALALARMS tf 17(.OWNER/OPERATOR SIGNATURE I ci:64 the in on provided herein iS uc and accur-Atc to the hest of my knowledge. 470_ 472. AM �C�WNE /,QPF aT (print): 1111.E OF OWNF,R/OPERATOR: t W w n Permit Number(Agency 9:.nn:y) 473. Permit Approved By(Agency use only) 474 1 Permit Expiration Date(Agency me only) 475. UPCF hwfwre-h(i/")-3/4 htIP://www.unid0Cs.4Pg Rev.02/10/00