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` UNIFIED PROGRAM CONSOLIDATED FORM TANKS UNDERGROUND STORAGE TANKS -TANK PAGE 2 amagma �r r� t F/11JGQNS R' ONhe kafffia a l r � VfPI Tt f c f ny �� , 'n"1u >�, ". - se k,�w .>�i,..:�.,&�. ��' i,�srr.'..;-. ,mss ,. � �:�. .re<.�.:a .. (,s �nz�� :.•, .,ss >.,.s .,,aP ,., UNDERGROUND PWING ABOVEGROUND PIPING SYSTEM TYPE & PRESSURE r 2. SUCTION r 3. GRAVITY r 1. PRESSURE r 2. SUCTION r 3. GRAVITY 459 FR RUCTION/ r 1. SINGLE WALL r 3. LINED TRENCH r99. OTHER r 1. SINGLE WALL 1-95. UNKNOWN 462 ACTURE DOUBLE WALL r 95. UNKNOWN r 2. DOUBLE WALL r 99. OTHER MANUFACTURER I'1. �) S�� l VTi 461 MANUFACTURER 463 r 1.BARE STEEL r 6. FRP COMPATIBLE Wl 100%METHANOL IF 1. BARE STEEL r 6. FRP COMPATIBLE W9 100%METHANOL MATERIALS AND r 2. STAINLESS STEEL r 7. GALVANIZED STEEL r 2. STAINLESS STEEL r 7. GALVANIZED STEEL CORROSION PROTECTION r 3 PLASTIC COMPATIBLE WITH CONTENTS r 95. UNKNOWN r 3. PLASTIC COMPATIBLE WITH CONTENTS r B. FLEXIBLE(HDPE) 1'99. OTHER 4. FIBERGLASS r 8. FLEXIBLE(HDPE) IF 99. OTHER r 4. FIBERGLASS r 9. CATHODIC PROTECTION r 5. STEEL W COATING r 9. CATHODIC PROTECTION 464 r 5. STEEL VW COATING r 95. UNKNOWN 465 1PliEEA�OEtx„�ION( h lrlttha !y "' s�l°t � iiraglaafxb�u lei .ed��ese� p . ., <. x �. . k. UNDERGROUND PIPING ABOVEGROUND PIPING SINGLE WALL PIPING 466 SINGLE WALL PIPING 467 PRESSURIZED PIPING(Check all that apply): PRESSURIZED PIPING(Check all that apply): r 1. ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP SHUT OFF FOR r 1. ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP SHUT OFF FOR LEAK LEAK SYSTEM FAILURE,AND SYSTEM DISCONNECTION+AUDIBLE AND VISUAL SYSTEM FAILURE,AND SYSTEM DISCONNECTION+AUDIBLE AND VISUAL ALARMS ALARMS r 2. MONTHLY 0.2 GPH TEST r 2. MONTHLY 0.2 GPH TEST r 3. ANNUAL INTEGRITY TEST(0.1 GPH) I' 3. ANNUAL INTEGRITY TEST(0.1 GPH) r 4. DAILY VISUAL CHECK CONVENTIONAL SUCTION SYSTEMS: CONVENTIONAL SUCTION SYSTEMS(Check all that apply): r 5. DAILY VISUAL MONITORING OF PUMPING SYSTEM+TRIENNIAL PIPING INTEGRITY r 5. DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM TEST(0.1 GPH) r 6. TRIENNIAL INTEGRITY TEST(0.1 GPH) SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): r 7. S ELF MONITORING r 7. SELF MONITORING GRAVITY FLOW. GRAVITY FLOW(Check all that apply): r 9. BIENNIAL INTEGRITY TEST(0.1 GPH) r 8. DAILY VISUAL MONITORING r 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 ALARMS AND (Check one) 10. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL ALARMS AND(check one) T AUTO PUMP SHUT OFF WHEN A LEAK OCCURS r a. AUTO PUMP SHUT OFF WHEN A LEAK OCCURS AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM r DISCONNECTION b.AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM DISCONNECTION (( �' r c. NO AUTO PUMP SHUT OFF r c, NO AUTO PUMP SHUT OFF 11. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)WITH FLOW SHUT OFF OR r 11. AUTOMATIC LEAK DETECTOR RESTRICTION r 12. ANNUAL INTEGRITY TEST(0.1 GPH) r 12. ANNUAL INTEGRITY TEST(0.1 GPH) SUCTION/GRAVITY SYSTEM: SUCTION/GRAVITY SYSTEM: r 13. CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS r 13. CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS EMERGENCY GENERATORS ONLY(Check all that apply) EMERGENCY GENERATORS ONLY(Check all that apply) r 14. CONTINUOUS SUMP SENSOR WITHOUTAUTO PUMP SHUT OFF+AUDIBLE AND ]' 14. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF+AUDIBLE AND VISUAL VISUAL ALARMS ALARMS r 15. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)WITHOUT FLOW SHUT OFF OR r 15. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST) RESTRICTION r 16. ANNUAL INTEGRITY TEST(0.1 GPH) r 16. ANNUAL INTEGRITY TEST(0.1 GPH) r 17. DAILY VISUAL CHECK r 17. DAILY VISUAL CHECK '01 DISPENSER CONTAINMENT r 1. FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE r 4. DAILY VISUAL CHECK DATE INSTALLED 468-A. CONTINUOUS DISPENSER PAN SENSOR+AUDIBLE AND VISUAL ALARMS r 5. TRENCH LINER/MONITORING r 3. CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR DISPENSER+AUDIBLE AND VISUAL ALARMS I'6. NONE 469 I certify that the information provided herein is true and accurate to the best of my knowledge. SIGNAT FOWN OPER DATE 470 NAME OF OVVNER/OPERAIT/.OR-(paint) 471 TITL OF OVMIE PERAT R 472 -L C-,E m Permit Number(For local use only) 473 provlWrlocal use only) 474 Permit Expiration Date(For local use only) 475