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B r UNIFIED PROGRAM CONSOLIDATED FORM TANKS UNDERGROUND STORAGE TANKS -TANK PAGE 2 Pace of VI.PIPING CONSTRUCTION(Check sA that sppt4 UNDERGROUND PIPING ABOVEGROUND PIPING SYSTEM TYPE 011, PRESSURE ❑ 2. SUCTION ❑ 3 GRAVITY ❑ 1. PRESSURE ❑ 2. SUCTION ❑ 3 GRAVITY _ CONSTRUCTION/ ❑;,1SINGLE WALL ❑ 3. LINED TRENCH ❑99 OTHER ❑ 1 SINGLE WALL ❑95 UNKNOWN MANUFACTURER 2 DOUBLE WALL ❑95. UNKNOWN ❑ 2. DOUBLE WALL ❑99 OTHER. MANUFACTURER MANUFACTURER ❑ 1.BARE STEEL ❑ 8. FRP COMPATIBLE WI 100%METHANOL ❑ 1. BARE STEEL ❑ 8. FRP COMPATIBLE W/100%METHANOL MATERIALS AND ❑ 2, STAINLESS STEEL ❑ T GALVANIZED STEEL ❑ 2. STAINLESS STEEL ❑ 7. GALVANIZED STEEL CORROSION PROTECTION ❑ 3. STIC COMPATIBLE WITH CONTENTS ❑95 UNKNOWN ❑ 3 PLASTIC COMPATIBLE WITH CONTENTS ❑ 8 FLEXIBLE(HDPE) ❑99. OTHER 4. FIBERGLASS ❑ S. FLEXI8LE(HOPE) ❑99. OTHER. ❑ 4 FIBERGLASS ❑ 9. CATHODIC PROTECTION ❑ 5. STEEL W/COATING ❑ 9. CATHODIC PROTECTION ❑ S STEEL Wl COATING ❑95. UNKNOWN VII.PIPING LEAK DETECTION(Cheek alf that apply) UNDERGROUND PIPING ABOVEGROUND PIPING SINGLE WALL PIPING INGLE WALL PIPING PRESSURIZED PIPING(Check aB that apply): PRESSURIZED PIPING(Check as that apply). ❑ 1. ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP SHUT OFF FOR ❑ 1. ELECTRONIC LINE LEAK DETECTOR 3.0 GPM TEST WITH AUTO PUMP SHUT OFF FOR LEAK, LEAK,SYSTEM FAILURE.AND SYSTEM DISCONNECTION•AU018LE AND VISUAL SYSTEM FAILURE,AND SYSTEM DISCONNECTION AUDIBLE AND VISUAL ALARMS ALARMS 2 MONTHLY 0 2 GPH TEST ❑ 2. MONTHLY 0 2 GPM TEST ❑ 3 ANNUAL INTEGRITY TEST(0.1 GPH) ❑ 3 ANNUAL INTEGRITY TEST(0.1 GPM) ❑ 4. DAILY VISUAL CHECK CONVENTIONAL SUCTION SYSTEMS'. CONVENTIONAL SUCTION SYSTEMS(Check a/f that apply): ❑ 5 DAILY VISUAL MONITORtNC OF PUMPING SYSTEM•TRIENNIAL PIPING INTEGRITY ❑ 5 DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM TEST 10 1 GPH) ❑ 8 TRIENNIAL INTEGRITY TEST(0.1 GPH) 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 all that apply): ❑ 9. BIENNIAL INTEGRITY TEST(0 1 GPH) ❑ 8 DAILY VISUAL MONITORING ❑ 9 BIENNIAL INTEGRITY TEST(O 1 GPH) SECONDARILY CONTAINED PIPING SECONDARILY CONTAINED PIPING PRESSURIZED PIPING(Chock as that apply): PRESSURIZED PIPING(Check s9 that apply) 10 CON US TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL ALARMS AND (Ck one) 10.CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL ALARMS AND(check one) El TO 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 PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM DISCONNECTION DISCONNECTION ,�/❑ c. NO AUTO PUMP SHUT OFF ❑ C. NO AUTO PUMP SHUT OFF E 11. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)WITH FLOW SHUT OFF OR ❑ it. AUTOMATIC LEAK DETECTOR RESTRICTION ❑ 12. ANNUAL INTEGRITY TEST(0 1 GPH) ❑ 12. ANNUAL INTEGRITY TEST(0.1 GPM) SUCTION/GRAVITY SYSTEM SUCTION(GRAVITY SYSTEM: ❑ 13 CONTINUOUS SUMP SENSOR•AUDIBLE AND VISUAL ALARMS ❑ 13. CONTINUOUS SUMP SENSOR s AUDIBLE AND VISUAL ALARMS EMERGENCY GENERATORS ONLY(Check a9 that apply) EMERGENCY GENERATORS ONLY(Check as that apply) ❑ 14 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 LINE LEAK DETECTOR(3.0 GPM TEST)WITHOUt FLOW SHUT OFF OR ❑ 15 AUTOMATIC UNE LEAK DETECTOR(3.0 GPM TEST) RESTRICTION ❑ 18. ANNUAL INTEGRITY TEST(0.1 GPH) ❑ 18. ANNUAL INTEGRITY TEST(0.1 GPH) ❑ 17. DAILY VISUAL CHECK ❑ 17. DAILY VISUAL CHECK VII.DISPENSER CONTAINMENT DISPENSER CONTAINMENT ffftAT MECHANISM THAT SHUTS OFF SHEAR VALVE ❑ 4. DAILY VISUAL CHECK DATE INSTALLED ❑2. CONTINUOUS DISPENSER PAN SENSOR•AU0I13LE AND VISUAL ALARMS ❑ S. TRENCH LINER/MONITORING ❑ 3. CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR DISPENSER•AUDIBLE AND VISUAL ALARMS ❑ 8. NONE IX.OWNER/OPERATOR SIGNATURE 1 earbty that the information provided heroin is V and ocsurate to the best of my krwwte e. SIGNATURE OF OWNERIOPERATOR -1 DATE n e� NAME OF OWNERiOPERATOR(print) TITLE OF ER/OPE R Pannil Number(For potsl use oMy) Pe-it Approved(For loeel uss only) Partnit Expiration Date(For local w9 oMy) 1 CUPAFORM(4199) Formerly SWRCS Form 13