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NIFIED PROGRAM CONSOLIDATED FORM TANKS UNDERGROUND STORAGE TANKS - TANK PAGE 2 Pae 2 of 2 VI.PIPING CONSTRUCTION(Check all that apply) UNDERGROUND PIPING ABOVEGROUND PIPING SYSTEM TYPE MI.PRESSURE. ❑2.SUCTION ❑3.GRAVITY 458. ❑1.PRESSURE ❑2.SUCTION ❑3.GRAVITY 459. CONSTRUCTION/ ❑ I,SINGLE WALL ❑3.LINED TRENCH ❑99.OTHER 460. ❑L SINGLE WALL ®95.UNKNOWN 462. MANUFACTURER 2,DOUBLE WALL ❑95.UNKNOWN ❑2.DOUBLE WALL ❑99.OTHER MANUFACTURER 461• 1 MANUFACTURER 463. [11.BARE STEEL ❑6.FRP COMPATIBLE W/100%METHANOL [11.BARE STEEL ❑6.FRP COMPATIBLE W/100%METHANOL ❑2.STAINLESS STEEL [17.GALVANIZED STEEL ❑2.STAINLESS STEEL ❑7.GALVANIZED STEEL ❑3.PLASTIC COMPATIBLE WITII CONTENTS [195.UNKNOWN [13.PLASTIC COMPATIBLE W/CONTENTS ❑8.FLEXIBLE(HDPE) ❑99.OTHER P.FIBERGLASS ❑8.FLEXIBLE(HDPE) ❑99.OTHER ❑4.FIBERGLASS ❑9.CATHODIC PROTECTION ❑5.STEEL W/COATING ❑9,CATHODIC PROTECTION 464. ❑S.STEEL W/COATING ®95.UNKNOWN 465. VII.PIPING LEAK DETECTION(Check all that apply) A criptionofthemonitoring prograin shall be submitted to the local agency.) 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 3.0 GPFI TEST WITH AUTO PUMP SHUT-OFF FOR LEAK,SYSTEM FAILURE,AND SYS'T'EM DISCONNECTION SHUT OFF FOR LEAK,SYSTEM FAILURE,AND SYSTEM DISCONNECTION +AUDIBLE AND VISUAL ALARMS. +AUDIBLE AND VISUAL ALARMS. [12. MONTHLY 0.2 GPH TEST [12, 'MONTHLY 0.2 GPH TEST 03. ANNUAL INTEGRITY TEST(0.1 GPH) [3 3. ANNUAL INT'EGRITYTEST(0.IGPH) ❑4. DAILY VISUAL CHECK CONVENTIONAL SUCTION SYSTEMS CONVENTIONAL SUCTION SYSTEMS(Check all that apply) ❑5. DAILY VISUAL MONITORING OF PUMPING SYSTEM-1-TRIENNIAL PIPING [15. DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM INTEGRITY TEST(0.1 GPH) SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): E16. TRIENNIAL INTEGRITY TEST(0.t GPH) ❑7. SELF MONITORING SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): GRAVITY FLOW ❑7. SELF MONITORING [19. BIENNIAL INTEGRITY TEST(0.1 GPH) GRAVITY FLOW(Check all that apply): ❑8. DAILY VISUAL MONITORING E19. BIENNIAL INTEGRITY TEST(0.1 GPI-I) SECONDARILY CONTAINED PIPING SECONDARILY CONTAINED PIPING PRESSURIZED PIPING(Check all that apply): PRESSURIZED PIPING(Check all that apply): 10. CONT OUS TURBINE SUMP SENSOR WITI[ AUDIBLE AND VISUAL 10. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL AL M AND(Check one) ALARMS AND(Check one) UTO PUMP SHUT OFF WHEN A LEAK OCCURS C1 a. AUTO PUMP SHUTOFF WHEN A LEAK OCCURS a b. AUI'0 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 ❑e. NO AUTO PUMP SHUT OFF &II. AUTOMATIC LINE LEAK DBTFCTOR(3.0 GPH TEST)WITFI FLOW SHUT ❑ 11. AUTOMATIC LEAK DETECTOR OFF OR RESTRICTION [112. ANNUALINITGRITYTEST(0.1 GPH) [112. ANNUAL INTEGRITYTEST(0.L GPH) SUCTION/GRAVITY SYSTEM SUCTION/GRAVITY SYSTEM [113. CONTINUOUS SUMP SENSOR i-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 SHUTOFF ❑ 14. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF AUDIBLE AND VISUAL ALARMS AUDIBLE AND VISUAL ALARMS ❑15. AUTOMATIC: LINE LEAK DETECTOR (3.0 GPII TEST) WITHOUT FLOW E:115. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST) SHUTOFF OR RESTRICTION ❑16. ANNUAL,INTEGRITY TEST(0.1 GPII) ❑16. ANNUAL INTEGRITY TEST(0.1 GPH) ❑17. DAILY VISUAL CHECK ❑ 17, DAILY VISUAL CHECK VIll.DISPENSER CONTAINMENT DISPENSER CONTAINMENT 463. FLOATMEC[IANISM THATSHUTS OFF SHEAR VALVE [14. DAILY VISUAL,CHECK 469. DATE INSTALLED 112, CONTINUOUS DISPENSER PAN SENSOR+AUDIBLE AND VISUAL ALARMS ❑5. TRENCII/LINF.R MONITORING q Q ❑3. CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR ❑6. NONE 1 O DISPENSER+AUDIBLE AND VISUAL ALARMS IX.OWNER/OPERATOR SIGNATURE I certify that the information provided herein is true and accurate to the best of my knowledge. SIGNATURE OFOWNEFUOPERATOR DATE: II/24/05 v 470' NAME OF OWNER/OPERATOR(print): Christopher R.Pecoraro TITLE OF OWNER/OPENATOR: SRVP 472. Permit Number(Agency use only) 473. Permit Approved By(Agency use onty) 474. 1 Pennit Expiration Date(Agency use only) 475. UPCF hwfwrc-b(1/99)-3/4 http://www.unidoes.oi,g Rev.02/16/00