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Ask UNIFIED PROGRAM CONSOLIDATED FORM TANKS UNDERGROUND STORAGE TANKS -TANK PAGE 2 VL PIPING CONSTRUC,ION(Chock ad trAtapp" UNCERGRCUNO PIPING I ASCVEGRCUNO PIPING SYSTEM TYPE z�1 PRESSURE ❑ 2. SUCTICN oP ❑ 3 GRAVITY.❑ 1. ESSURE ❑ z suc-lcN ❑ 3. cRAVCr cc STRUCTIC`L Cl I SiNGLE'/'1ALL ❑ 3. LINEDTRENCH 0i9. OiHER ❑ 1 SINGL=WALL 095. UNKNC'A'N MANUFACTURER (92. COUdL=WALL ❑9S. UNKNOWN ❑ 2. OOUBL-:WALL ❑99. OTHER ! ( MANUFACTURER /�?• :.?- S`tet MANUFACTURER ❑ 1.BARE STEEL ❑ 8. FRP COMPATIBLE W1 100%METHANOL ❑ 1. BARE STEEL ❑ 8. FRP COMPATIBLE vw 100%METHANOL MATERIALS AND ❑ 7- STAINLESS STEEL ❑ 7. GALVANIZED STEEL ❑ 2. STAIM.ESS STEEL ❑ 7. GALVANIZED STEEL CORROSION PROTECTION �❑3 3. PLASTIC COMPATIBLE WITH CONTENTS 1195. UNKNOWN C3TIC 3. PLASCOMPATIBLE WITH CONTENTS 138. FLEXIBLE(HOPE) C399. OTHER C51`4.4. FIBERGLASS ❑ S. FLEXIBLE(HDPE) ❑99. OTHER ❑ 4. FIBERGLASS ❑ 9. CATHODIC PROTECTION ❑ 5. STEEL W/COATING ❑ 9.CATHODIC PROTECTION ❑ 5. STEEL WI COATING ❑95. UNKNOWN V1L PIPING LEAK DETECTION(Chock of drat appy) UNDERGROUND PIPING ABOVEGROUNO PIPING j SINGLE WALL PIPING SINGLE WALL PIPING - PRESSURIZED PIPING(Check aha that aptly): PRESSURIZED PIPING(Chock ad that apply): ❑ 1. ELECTRONIC UNE LEAK OE i EC-.OR 3.0 GPM TEST'MTH AUTO PUMP SHUT OFF FOR ❑ 1. ELECTRONIC UNE LEAK DETECTOR 3.0 GPM TEST WITH AUTO PUMP SHUT OFF FOR LEAK. LEAK,SYSTEM FAILURE.AND SYSTEM DISCONNECTION•AUDIBLE AND VISUAL SYSTEM FAILURE,AND SYSTEM DISCONNECTION•AUDIBLE ANO VISUAL ALARMS ALARMS ❑ 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. GAILY VISUAL CHECK CONVENTIONAL SUCTION SYSTEMS. CONVENTIONAL SUCTION SYSTEMS(Check ad that appy): ❑ S. DAILY VISUAL MONITORING OF PUMPING SYSTEM•TRIENNIAL PIPING INTEGRITY ❑ S. DAILY VISUAL MCNITORING OF PIPING AND PUMPING SYSTEM TEST(0.1 GPM) ❑ 5. TRIENNIAL INTEGRITY TEST(0.1 GPM) SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): ❑ 7. SELF MONITORING ❑ 7. SELF MONITORING GRAVITY FLOW GRAVITY FLOW(Check ad Mat appy): C' BIENNIAL INTEGRITY TEST(0.1 GPM) ❑ 8. OAILY VISUAL MONITORING ❑ 9. BIENNIAL INTEGRITY TEST(0.1 GPM) SECONDARILY CONTAINED PIPING SECONDARILY CONTAINED PIPING PRESSURIZED PIPING(Check all that so*): PRESSURIZED PIPING(Cheek of that appy): 10. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL ALARMS AND 10.CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL ALARMS AND Check oho) (cC�1sa ane) ( kc9�a AUTO PUMP SHUT CFF'AMEN A LEAK OCCURS ❑ a.AUTO PUMP SHUT CFF WHEN A LEAK OCCURS }eT o AUTO PUMP SMUT CFF FCR LEAKS.SYSTEM FAILURE AND SYSTEM ❑ ! OtSCONNECTION 0 AUTO PUMP SHUT CFF FOR LEAKS,SYSTEM FAILURE AND SvSTEM OISCCNNECT:CN ❑ c NO AUTO PUMP SHUT CFF ❑ C. NO AUTO PUMP SMUT OFF 11 AUTOMATIC UNE LEAK CETEECTCR(3.0 GPM TEST)WITH FLOW SHUT OFF CR ❑ 11 AUTOMATIC LEAK OETEC-CR RESTRICTION Q 12. ANNUAL INTEGRITY TEST(0.1 GPM) ❑ 12. ANNUAL,INTEGRITY TEST(0.1 GPM) SUCTIONIGRAVITY SYSTEM: SUCTTON/GRAVtTY SYSTEM: ❑ 13. CONTINUOUS SUMP SENSOR-AUDIBLE AND VISUALALARMS ❑ 13. CONTINUOUS SUMP SENSOR•AUDIBLE ANO VISUAL ALARMS EMERGENCY GENERATORS ONLY(Check of Mat app" EMERGENCY GENERATORS ONLY(Check Ad Mat app" ❑ t4, CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF•AUDIBLE AND ❑ 14. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF•AUDIBLE AND VISUAL VISUAL ALARMS ALARMS ❑ 15.AUTOMATIC UNE LEAK DETECTOR(3.0 GPM TEST)WITHOUT FLOW SMUT OFF OR ❑ 15. AUTOMATIC UNE LEAK DETECTOR(3.0 GPM TEST) RESTRIC'ON ❑ 18. ANNUAL INTEGRITY TEST(0.1 GPM) ❑ 15. ANNUAL INTEGRITY TEST(0.1 GPM) ❑ 17. GAILY VISUAL CHECK ❑ 17. DAILY VISUAL CHECK VUL DISPENSER CONTAINMENT DISPENSER CONTAINMENT W 1. FLOAT MECHANISM THAT SMUTS OFF SMEAR VALVE ❑ 4. DAILY VISUAL CHECK DATE INSTAL!!-0 ,,✓f ❑ 2. CONTINUOUS DISPENSER PAN SENSOR•AUDIBLE AND VISUAL ALARMS ❑ 5. TRENCH UNER/MONITORING ��-�6- W!/" ❑ 3. CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR DISPENSER•AUOISLE AND VISUAL ALARMS ❑ e. NONE IX OWNERIOPERATOR SIGNATURE 1 cerJtY 71a(4t0 nta.eaeon Pmvuded Mena+m true and scml to to the Gest of my kmvAodge. SIG.rUt!TF OWN5POPERATCR DATE 3 0 NAME OF CWNERIC TCR(p^" 7fZE OF OPERATO 1 i S 'umber(For Ideal use only) FPennrt ORN*d(Forfoeal use only! permit Exp ravon Oat&(ForM(al use only) l CUPAFORM(4r99) Formerly SWRCS-:-n 3