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U D PROGRAM CONSOLIDATED FORM TANKS UNDERGROUND STORAGE TANKS-TANK PAGE 2 Pae of=rl V1.PIPING CONSTRUCTION Cheek all that UNDERGROUND PIPING ABOVECTROUND PIPING SYSTFM TYPE lkf PRESSURE, ❑2.SUCTION ❑3.GRAVITY 458. ❑1.PRESSURE ❑2.SUCTION [13,GRAVITY 459. CONSTRUCTION/ ❑1. NGLE WALL ❑1-I..TNr.D TRENCH L199.OTHER 46o. ❑L SINGLE WALL ❑95.UNKNOWN 462 MANUFACTURER MJUBLE WALL ❑95.UNKNOWN ❑2-DOUBLE WALL ❑99.OTHER MANUFACTURER ( 461 MANUFACTURER 463 ❑ L HARE STEEL ❑6.FRP COMPATIBLE W/100a/METHANOL ❑1.RARE STEEL ❑6.FRP COMPATIBLE W/l OD%METHANOL ❑2.STAINLFSS STEEL ❑7-GAi.VAN17m)STEEL. C}2.STAINLESS STEEL ❑7.GALVANIZED STEEL ❑3.PLASTIC COMPATIBLE WITH CONTENTS [19.5-UNKNOWN ❑3.PLASTIC COMPATIBLE W/CONTENTS ❑R.FLEXIBLE(HDPE) ❑99.OTHER ❑4.FIBERGLASS ❑R.FLEXIBLE(HDPE) [199-OTHER ❑4.FIBERGLASS ❑9.CATHODIC PROTECTION ❑5.STEEL WlCOATING ❑9.CATHODIC PROTECTION UA ❑5.STFEL W/CRATING ❑95.UNKNOWN 465. V IL PIPING LEAK DETECTION Chuck all tluf )(A iption o f the naoadofjng pmgrzan shall be sttbtrtiucd to the kit a y. IINDFRGROUND PIPING ABOVEGROUND PIPING SINGLE WALL PIPING SINGLE WALL.PIPING 467. 7URIZED PIPING(Cbeck all that apply)- PRESSURIZED PIPING(Cheek all No apply): ELECTRONIC LINE LEAK DETECTOR 3.0 GPIs TEST WITH AUTO PUMP ❑1- FLPCTRONIC LiNE LFAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP SHAT-OFF FOR TEAK-SYSTEM FAILURE,AND SYSTRM DiSCONNECTiON SM IT OFF FOR LRAK,SYSTEM FAILLIRF„AND SYSTEM DISCONNECTION +AUDIBLE-AND VISUAL ALARMS. +AUDIBLE AND VISUAL ALARMS. (12, MONTHLY 02 GPU TEST [12. MONTHLY 0.2 GPH TEST [13. ANNt1A1.INTFCTRITY TEST(0.1 QYH) [33. ANNUAL INTEGRITY TEST(0.1 OPH) 04- DAILY VISUAL CHECK CONVENTIONAL.SUCTION SYSTEMS CONVENTIONAL SUCTION SYSTEMS(Check till that apply) ❑5. DAILY VISUAL MONITORING OF PUMPING SYSTEM+TRIENNIAL PIPING [35. DAILY VISUAL MONITORING OF PIPING AND PIJMPTNG SYSTEM INTEGRITY TEST(0-1 GPH) SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PiPiNG); E]6. TRIENNIAL INTEGRITY TEST(0.1 GPH) []7- SELF MONITORING SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): GRAVITY FLOW ❑7. SELF MONITORING C19. BIENNIAL INTEGRITY TEST 10.1 GPH) GRAVITY FLOW(Check all that apply): ❑R. DAILY VISUAL MONITORING C]9. BIENNIAL INLFGRITv TEST(0.I(iPH) 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 VISUAi. 10. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL Ai.A RMS ANi)(Check one) ALARMS AND(Check one) [AUTO PUMP SITUi'OFF WHEN A LEAK OCCURS ❑a. AUTO PUMP SHUT OFF WITEN A LEAK OCCURS ❑b.AUTO PUMP SHOT OFF FOR LEAKS,SYSTFM FAILLIRF AND SYSTEM ❑b.AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM DISCONNECTiON DISCONNF.CTION ❑c. NO AU TOPIJMPSDIJTOIT ❑c. NOAIITOPIIMPSIH)TOPF 11AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)WiTH FLOW SHUT ❑11 AUTOMATIC TEAK DETECTOR OFF OR RESTRICTION ❑12. ANNUAL INTEGRITY TEST(0.1 GPH) ❑12.ANNUAL INTEGRITY TEST(0.1 GPH) SUCTIONIGRAViTY SYSTFM SUCTiONIGRAVITY S1'9FEM ❑13. CONTINUOiS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS ❑1'1.CONTINUOUS STUMP SENSOR+AUDIBLE AND ViSUAL ALARMS EMERGENCY GENERATORS ONLY(Check all th:a apply) EMERGENCY GENERATORS ONLY(Cbeck all that apply) ❑14. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF ❑14. CONi1NIJOUS SUMP SENSOR Wi FOUT AUTO PUMP S)TUT OFF AUDIBLE AND VISUAL ALARMS AUDIBLE AND VISUAL.AT ❑15. AUTOMATIC LINE LEAK DETECTOR (3.0 GPH TFST) WITHOUT FLAW ❑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) [117. DAiLY VISUAL CHECK ❑IT DAILY VISUAL CHECK VIII.DISPENSER CONTAINMENT DISPENSER CONTAINMENT 469. []1. FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE DAILY VISUAL CHECK 469. DATE INSTA Ell [12. CONTINUOUS DISPENSER PAN SENSOR+AUDIBi-E AND ViSUAL ALARMS ❑5. TRENCH(LINER MONITORING ❑3. CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SiIUT OFF FOR �/NONE DISPENSER+AUDIBLE AND VISUAL ALARMS IX.OWNF.R/OPERATOR SIGNATURE I certify the i cin is true and accurate to the best of my knowledge. 470- 472. 7AMEOFAWFF1R/OP:R T V i t): 711T.EOP WNF,R/OP 2R116R_ Permit Number(Agency uNe n ly) 473. Permit Approved By(Agency use truly) 474 1 Permit Expiration Date(Agency we only) 475. UPCF hwfwre-h(1199)-3/4 http://www.unidoes.ai% Rev.02/10/00