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L F CP D PROGRAM CONSOLIDATED FOFW TANKS 7 UNDERGROUND STORAGE TANKS-TANK PAGE 2 Pae of VL PIPING CONSTRUCTION(Chert aA that apply) UNDERGROUND PIPING ABOVEGROUND PIPING SYSTEM TYPE 19 1.PRESSURE ❑2.SUCTION ❑3.GRAVITY 458- ❑1.PRESSURE ❑2.SUCTION ❑3.GRAVITY 459. CONSTRUCTION/ ❑1.SINGLE WALL ❑3.LINED TRENCH 1199.OTHER 460. ❑1-SINGLE WALL ❑95.UNKNOWN 462. MANUFACTURER ry 2.DOUBLE WALL ❑95.UNKNOWN ❑2-DOUBLE WALL. ❑99.OTHER MANUFACTURER 46t. MANUFACTURER 463. ❑1.BARE STEEL ❑6.FRP COMPATIBLE W/100•/.METHANOL ❑L BARE STEEL ❑6.FRP COMPATIBLE W/100%METHANOL ❑2.STAWLESS 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 IX4.FIBERGLASS ❑8.FLEXIBLE(HDPE) ❑99.OTHER ❑4.FIBERGLASS ❑9.CATHODIC PROTECTION ❑5.STEEL.W/COATING 119.CATHODIC PROTECTION 464. ❑5.STEEL W/COATING ❑95.UNKNOWN 465. VII.PIPING LEAK DETECTION(Geek A that appty)(A of the mondow g sba8 be sobmroed to the k)cal agowy.) UNDERGROUND PIPING ABOVEGROUND PIPING SINGLE WALL PIPING 466 SINGLE WALL PIPING 467- 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 30 GPHTEST WITH AUTO PUMP SHUT-OFF FOR LEAK,SYSTEM FAR-URE,AND SYSTEM DISCONNECTION SHUT OFF FOR LAK,SYSTEM FAILURE,AND SYSTEM DISCONNECTION +AUDIBLE AND I ❑2. MONTHLY 02 GPH TEST ALARMS- I ❑2" MONTHLY 0.2 GPH VISUAL TEST ALARMS. II ❑3- ANNUAL INTEGRITY TEST(0.1 GPM [13. ANNUAL INTEGRITY TEST(0.1 GPH) 04. DAILY_vISUAL CHECK CONVENTIONAL SUCTION SYSTEMS CONVENTIONAL SUCTION SYSTEMS(Chuck all that apply) ❑5. DAILY VISUAL MONITORING OF PUMPING SYSTEM+TRM'MAL PIPING []5. DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM INTEGRITY TEST(0.1(SRH) SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): [16. TRIENMAL INTEGRITY TEST(O.I GPH) ❑7. SELF MONITORING SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): GRAVITY FLOW [17. SELF MONITORING ❑9. BTINNIAL INTEGRITY TEST(0.1 GPH) GRAVITY FLOW(Check all that apply): ❑8. 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 WTIH AUDIBLE AND VISUAL 10. CONTINUOUS TURBINE SUMP SENSOR W[TH AUDIBLE AND VISUAL ALARMS AND(Check one) ALARMS AND(Check one) 10 a_ AUTO PUMP SHUT OFF WHEN A LEAK OCCURS ❑a"AUTO PUMP SHUT OFF WHEN A LEAK OCCURS 14b.AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM b.AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM DISCONNECTION DISCONNECTION / ❑c. NO AUTO PUMP SHUT OFF [1c NO AUTO PUMP SHUT OFF L3 11. AUTOMATIC LINE LEAKDETECTOR(3.0 GPH TEST)WIT FLOW SHUT 5911.AUTOMATIC LEAK DETECTOR OFF OR RESTRICTION ❑12. ANNUAL INTEGRITY TEST(0.1 GPM ❑12.ANNUAL INTEGRITY TEST(0.1 GPH) SUCTION/GRAVITY SYSTEM SUCTION/GRAVIIY SYSTEM ❑13. CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS M43- 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 [114.CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SENT OFF AUDIBLE AND VISUAL ALARMS AUDIBLE AND VISUAL ALARMS ❑I5. 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) ❑16.ANNUAL INTEGRITY TES(0.1 GPI ❑17. DAILY VISUAL CHECK ❑17.DAILY VISUAL CHECK VIII.DISPENSER CONTAINMENT DISPENSER CONTAINMENT 468. ❑I" FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE ❑4. DAILY VISUAL CHECK 469. DATE INSTALLED ❑2. CONTINUOUS DISPENSER PAN SENSOR+AUDIBLE AND VISUAL ALARMS ❑5. TRENCII/LINER MONITORING [13, CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR ❑6 NONE DISPENSER+AUDIBLE AND VISUAL ALARMS II{.OWNER/OPERATOR SIGNATURE I certify that the information provided herein is true and accurate to the best o trty knowledge. SIGNATURE OF OWNER/OPERATO)1 5 DATE: v 03 o 470.-- 471. NAME OF OWNER/OPERATOR(point): TITLE OF OWNER/OPERATOR. C, C U/V -T R A C 7-OR Permit Number(Agency use only) 473. Permit Approve y(Agency use only) 474. Permit Expiration Date(Agency use only) 475.