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e UNIFIED PROGRAM CONSOLIDATED FORM TANKS UNDERGROUND STORAGE TANKS-TANK PAGE 2 UNDERGROUND PIPING VI.PIPING CONSTRUCTION(Check ad that appy - - SYSTEM TYPE A80VEGROUND PIPING 1. PRESSURE ❑ 2. SUCTION ❑ 3. GRAVITY ❑ 1. PRESSURE ❑ 2. SUCTION C3 3. GRAVITY CONSTRUCTION/ ❑,_,/1 SINGLE WALL 113. LINED TRENCH ❑99 OTHER ❑ 1. SINGLE WALL MANUFACTURER n 2 DOUBLE WALL ❑95. UNKNOWN ❑95. UNKNOWN MANUFACTURER ❑ 2. DOUBLE WALL ❑99. OTHER MANUFACTURER 11i.BARE STEEL ❑ 6. FRP COMPATIBLE W/100%METHANOL ❑ 1. BARE STEEL MATERIALS AND ❑ 2. STAINLESS STEEL ❑ 7. GALVANIZED STEEL ❑ 6. FRP COMPATIBLE W/100%METHANOL CORROSION ❑ 2. STAINLESS STEEL ❑ 7. GALVANIZED STEEL PROTECTION ❑ 3. PLASTIC COMPATIBLE WITH CONTENTS ❑95. UNKNOWN ❑ 3. PLASTIC COMPATIBLE WITH CONTENTS ❑ S. FLEXIBLE(HDPE) ❑99. OTHER ❑ 4. FIBERGLASS ❑ 8. FLEXIBLE(HDPE) 1190 OTHER. ❑ 4. FIBERGLASS ❑ 5. STEEL W/COATING ❑ 9. CATHODIC PROTECTION ❑ 5. 11 9. CATHODIC PROTECTION STEEL W/COATING ❑95. UNKNOWN VII.PIPING LEAK DETECTION(Cheel ad Net appy) UNDERGROUND PIPING SINGLE WALL PIPING ABOVEGROUND PIPING PRESSURIZED PIPING(Check all that apoty): SINGLE WALL PIPING PRESSURIZED PIPING(Check all that apply): ❑ 1. ELECTRONIC LINE LEAK DETECTOR 3.0 GPM TEST WITH AUTO PUMP SHUT OFF FOR ❑ 1. ELECTRONIC UNE LEAK DETECTOR 3.0 GPM TEST WITH AUTO PUMP SMUT OFF FOR LEAK, , LEAKSYSTEM FAILURE.AND SYSTEM DISCONNECTION+AUDIBLE ANO VISUAL ALARMS S SYSTEM FAILURE.AND SYSTEM DISCONNECTION;AUDIBLE AND VISUAL ALARMS L ❑ 2. MONTHLY 0 2 GPM TEST ❑ 2. MONTHLY 0.2 GPM TEST ❑ 3. ANNUAL INTEGRITY TEST(0.1 GPM) ❑ 3. ANNUAL INTEGRITY TEST(0.1 GPM) ❑ 4. DAILY VISUAL CHECK CONVENTIONAL SUCTION SYSTEMS: CONVENTIONAL SUCTION SYSTEMS Check all that a ) ❑ 5 DAILY VISUAL MONITORING OF PUMPING SYSTEM-TRIENNIAL PIPING INTEGRITY 115. DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM TEST(0 1 GPM) ❑ 6. TRIENNIAL INTEGRITY TEST(0.1 GPM) SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING)' ❑ 7. SELF MONITORING SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING)' GRAVITY FLOW ❑ 7. SELF MONITORING : ❑ 9. BIENNIAL INTEGRITY TEST(0.1 GPM) GRAVITY FLOW(Check ab that apply): ❑ 8. DAILY VISUAL MONITORING ❑ 9 BIENNIAL INTEGRITY TEST(0.1 GPM) SECONDARILY CONTAINED PIPING PRESSURIZED PIPING(Check all that apply): SECONDARILY CONTAINED PIPING 10 CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL ALARMS AND PRESSURIZED PIPING(Check all that apply): (Cneck ane) 10.CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL ALARMS AND(check ane) ❑ a AUTO PUMP SMUT OFF WHEN A LEAK OCCURS ❑ b AUTO PUMP SMUT OFF FOR LEAKS.SYSTEM FAILURE AND SYSTEM ❑ a.AUTO PUMP SHUT OFF WHEN A LEAK OCCURS DISCONNECTION ❑ b. AUTO PUMP SMUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM DISCONNECTION ❑ c. NO AUTO PUMP SHUT OFF ❑ C. NO AUTO PUMP SMUT OFF ❑ 11 AUTOMATIC LINE LEAK DETECTOR(3.0 GPM TEST)WITH FLOW SHUT OFF OR RESTRICTION ❑ 11. AUTOMATIC LEAK DETECTOR ❑ 12 ANNUAL INTEGRITY TEST(0.1 GPM) ❑ 12.ANNUAL INTEGRITY TEST(0.1 GPM) 3UCTION:GRAVITY SYSTEM' SUCTION/GRAVITY SYSTEM: ❑ 13 CONTINUOUS SUMP SENSOR-AUDIBLE AND VISUAL ALARMS ❑ 13. CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS EMERGENCY GENERATORS ONLY(Check as that apply) 1-1 14. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF. EMERGENCY GENERATORS ONLY(Check ad that apply) VISUAL ALARMS AUDIBLE AND ❑ 14.CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF+AUDIBLE AND VISUAL 15. AUTOMATIC LINE LEAK DETECTOR(3.0 GPM TEST)WITHOUT FLOW SHUT OFF OR ALARMS RESTRICTION ❑ 15. AUTOMATIC LINE LEAK DETECTOR(3.0 GPM TEST) ❑ 16. ANNUAL INTEGRITY TEST(0.1 GPM) ❑ 17. DAILY VISUAL CHECK - ❑ 16. ANNUAL INTEGRITY TEST(0.1 GPM) ❑ 17. DAILY VISUAL CHECK VII.DISPENSER CONTAINMENT DISPENSER CONTAINMENT ❑ 1. FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE DATE INSTALLED ❑ 2. CONTINUOUS DISPENSER PAN SENSOR+AUDIBLE AND VISUAL ALARMS 4. DAILY VISUAL CHECK 5. ❑ 3. CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR DISPENSER a AUDIBLE AND VISUAL ALARMS ❑6. NONE TRENCHLINER/MONITORING 1 cartIy Nat the in(onnabon provided herein is true and accurate to Ute best of my knovAed®eX.OWNER)OPERATOR SIGNATURE SIGNATURE OF CANE VOPERATOR GATE NAME OF OWNEWOPERATOR(pdnt) TITLE OFOWNER/OPERATOR Partnit Number(For local use only) Permit Approved(Forlocal use only) Pertni!Expiration Date(Forlocal use only) UPAFORM(4199) Formerly SWRCS Form B