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u IED PROG CONSOLIDATED FORt._ TANKS UNDERGROUND STORAGE TS-TANK PAGE 2 ' Pae of VL PIPING CONSTRUCTION Chockall that 1 UNDERGROUND PIPING ABOVEGROUND PIPING SYSTEM TYPE ❑1.PRESSURE ❑2.SUCTION ❑3.GRAVITY 45& ❑1.PRESSURE .10 2.SUCTION ❑3.GRAVITY 459. CONSTRUCTION/ ❑1.SINGLE WALL ❑3.LINED TRENCH ❑99.OTHER 460. ❑1.SINGLE WALL ❑95.UNKNOWN 462- MANUFACTURER 62 MANUFACTURER ❑2.DOUBLE WALL ❑95.UNKNOWN ❑2.DOUBLE WALL ❑99.OTHER MANUFACTURER 461. MANUFACTURER 463. 6.FRP COMPATIBLE W/100%METHANOL ❑1.BARE STEEL [16.FRP COMPATIBLE W/100%METHANOL ❑1.BARE STEEL ❑ ❑2.STAINLESS STEEL ❑7.GALVANIZED STEEL ❑2.STAINLESS STEEL ❑7 GALVANIZED STEEL ❑3.PLASTIC COMPATIBLE WITH CONTENTS ❑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 ❑95.UNKNOWN 465. 464. ❑5.STEEL W/COATING ❑9.CATHODIC PROTECTION ❑ VIL PIPING LEAK DETECTION Chak all that i A dcxer'tan of the tnonrto' a1 a1AB �otUN local ') UNDERGROUND PIPING 467. SINGLE WALL PIPING 466 SINGLE WALL PIPING PRESSURIZED PIPING(Check all that apply): PRESSURIZED PIPING(Check all that apply): ❑1. ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP ❑1. ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP SHUT-OFF FOR LEAK SYSTEM FAILURE,AND SYSTEM DISCONNECTION SHUT OFF FOR LEAK,SYSTEM FAILURE,AND SYSTEM DISCONNECTION + +AUDIBLE AND VISUAL ALARMS. AUDIBLE AND VISUAL ALARMS. ❑2. MONTHLY 0.2 GPH TEST [12. MONTHLY 0.2 GPH TEST []3. ANNUAL INTEGRITY TEST(O.1 GPH) ❑3. ANNUAL INTEGRITY TEST(0.1 GPH) ❑4. DAILY VISUAL CHECK CONVENTIONAL SUCTION SYSTEMS CONVENTIONAL SUCTION SYSTEMS(Check all that apply) ❑5. DAILY VISUAL MONITORING OF PUMPING SYSTEM+TRIENNIAL PIPING E15. DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM INTEGRITY TEST(0.1 GPH) SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): [16. TRIENNIAL INTEGRITY TEST(0.1 GPH) ❑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 FLOW(Check all that apply): [38. DAILY VISUAL MONITORING ❑9. BIENNIAL INTEGRITY TEST(0.1 GPH) 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 VISUAL 10. COAN�AND (Check SUMP SENSOR WITH AUDIBLE AND VISUAL ALARMS AND(Check one) ❑a.AUTO PUMP SHUT OFF WHEN A LEAK OCCURS ❑a.AUTO PUMP SHUT OFF WHEN A LEAK OCCURS ❑b.AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM ❑b.AUTO DISCONNECTION PUMPPSHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM DISCONNECTION ❑c. NO AUTO PUMP SHUT OFF ❑c. NO AUTO PUMP SHUT OFF ❑11. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)WITH FLOW SHUT ❑11.AUTOMATIC LEAK DETECTOR OFF OR RESTRICTION ❑12. ANNUAL INTEGRITY TEST(0.1 GPH) [112.ANNUAL INTEGRITY TEST(0.1 GPH) SSUCTION/GRAVITY SYSTEM UCTION/GRAVITY SYSTEM [113. CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS ❑ 13.CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS EMERGENCY GENERATORS ONLY(Check all that apply) EMERGENCY GENERATORS ONLY(Check all that apply) ❑14. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF [:]14.CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF AAUDIBLE AND VISUAL ALARMS AUDIBLE AND VISUAL ALARMS ❑15. AUTOMATIC LINE LEAK DETECTOR (3.0 GPH TEST) WITHOUT FLOW ❑15.AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST) SHUT OFF OR RESTRICTION ❑16. ANNUAL INTEGRITY TEST(0.1 GPH) [116.ANNUAL INTEGRITY TEST(0.1 GPH) ❑17. DAILY VISUAL CHECK ❑!7.DAILY VISUAL CHECK VUL DISPENSER CONTAINMENT DISPENSER CONTAINMENT 468. ❑1. FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE ❑4. DAILY VISUAL CHECK 469• DATE INSTALLED ❑2. CONTINUOUS DISPENSER PAN SENSOR+AUDIBLE AND VISUAL ALARMS ❑5. TRENCH/LINER MONITORING ❑3. CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR ❑6. NONE DISPENSER+AUDIBLE AND VISUAL ALARMS IXC OWNER/OPERATOR SIGNATURE I& tion provi herein is true d accurate to the best of my knowledge.- 470 i o3 472 :NAME T'It= T ( t� TITLE OFOWNER/OPE TOR 1 473. Pertttit roved B A en ttae onl 474. Permit Expiration Date(Agency use Only) 475. Permit Number(Agency use orgy) APP y( g c y) UPCF hwfwrc-b(1/99)-314 http://www.unidoes.org Rev.02/16/00