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UNIFIED PROGRAM CONSOLIDATED FORM <br /> TANKS <br /> UNDERGROUND STORAGE TANKS -TANK PAGE 2 <br /> VI.PIPING CONSTRUCTION(Check all that apply) <br /> UNDERGROUND PIPING ABOVEGROUND PIPING <br /> SYSTEM TYPE ❑ 1 PRESSURE ❑ 2. SUCTION ❑ 3 GRAVITY ❑ 1 PRESSURE ❑ 2. SUCTION ❑ 3. GRAVITY <br /> CONSTRUCTION/ ❑ 1. SINGLE WALL ❑ 3. LINED TRENCH ❑99. OTHER ❑ 1 SINGLE WALL ❑95. UNKNOWN <br /> MANUFACTURER ❑ 2, DOUBLE WALL ❑95. UNKNOWN ❑ 2. DOUBLE WALL ❑99. OTHER <br /> MANUFACTURER MANUFACTURER <br /> ❑ 1.BARE STEEL ❑ 8. FRP COMPATIBLE Wt 100%METHANOL ❑ 1. BARE STEEL ❑ 8. FRP COMPATIBLE W/100%METHANOL <br /> MATERIALS AND ❑ 2, STAINLESS STEEL ❑ 7. GALVANIZED STEEL ❑ 2. STAINLESS STEEL ❑ 7. GALVANIZED STEEL <br /> CORROSION <br /> PROTECTION ❑ 3. PLASTIC COMPATIBLE WITH CONTENTS ❑95 UNKNOWN ❑ 3 PLASTIC COMPATIBLE WITH CONTENTS ❑ 8. FLEXIBLE(MOPE) ❑99. OTHER <br /> ❑ 4. FIBERGLASS ❑ B. FLEXI8LE(HOPE) ❑99. OTHER. ❑ 4 FIBERGLASS ❑ 9. CATHODIC PROTECTION <br /> ❑ 5. STEEL WI COATING ❑ 9. CATHOOIC PP.OTECTION ❑ 5. STEEL W/COATING ❑95. UNKNOWN <br /> VII.PIPING LEAK DETECTION(Check aB that apply) <br /> UNDERGROUND PIPING ABOVEGROUND PtPING <br /> SINGLE WALL PIPING SINGLE WALL PIPING - <br /> PRESSURIZED PIPING(Check all that apply): PRESSURIZED PIPING(Check all that apply): <br /> ❑ 1. ELECTRONIC LINE LEAK DETECTOR 3.0 GPM TEST WITH AUTO PUMP SHUT OFF FOR ❑ 1. ELECTRONIC LINE LEAK DETECTOR 3.0 GPM TEST WITH AUTO PUMP SHUT OFF FOR LEAK, <br /> LEAK,SYSTEM FAILURE,AND SYSTEM DISCONNECTION+AUDIBLE AND VISUAL SYSTEM FAILURE,AND SYSTEM DISCONNECTION+AUOIBLE AND VISUAL ALARMS <br /> ALARMS ❑ 2. MONTHLY 0 2 GPM TEST <br /> ❑ 2. MONTHLY 0 2 GPM TEST <br /> ❑ 3 ANNUAL INTEGRITY TEST(0.1 GPM) <br /> ❑ 3 ANNUAL INTEGRITY TEST(0 1 GPM) ❑.4. DAILY VISUAL CHECK <br /> CONVENTIONAL SUCTION SYSTEMS. CONVENTIONAL SUCTION SYSTEMS(Check all that apply). <br /> ❑ 5. DAILY VISUAL MONITORING OF PUMPING SYSTEM-TRIENNIAL PIPING INTEGRITY ❑ 5. DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM <br /> TEST(0.1 GPM) ❑ 6. TRIENNIAL INTEGRITY TEST(0.1 GPM) <br /> SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING) SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING)' <br /> ❑ 7 SELF MONITORING ❑ 7. SELF MONITORING <br /> GRAVITY FLOW' GRAVITY FLOW(Check all that apply)' <br /> ❑ 9 BIENNIAL INTEGRITY TEST(0 1 GPM) ❑ 8 DAILY VISUAL MONITORING <br /> ❑ 9 BIENNIAL INTEGRITY TEST(0.1 GPM) <br /> SECONDARILY CONTAINED PIPING SECONDARILY CONTAINED PIPING <br /> PRESSURIZED PIPING(Check all that apply): PRESSURIZED PIPING(Check all that apply): <br /> 10 CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL ALARMS AND <br /> (Check ane) 10.CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL ALARMS AND(check one) <br /> ❑ a AUTO PUMP SHUT OFF WHEN A LEAK OCCURS Cl a. AUTO PUMP SHUT OFF WHEN A LEAK OCCURS <br /> ❑ b AUTO PUMPMUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM <br /> DISCONNECTION <br /> El AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM DISCONNECTION <br /> ❑ C. NO AUTO PUMP SHUT OFF ❑ C. NO AUTO PUMP SHUT OFF <br /> ❑ 11. AUTOMATIC LINE LEAK DETECTOR(3.0 GPM TEST)WITH FLOW SHUT OFF OR ❑ <br /> RESTRICTION 11. AUTOMATIC LEAK DETECTOR <br /> ❑ 12 ANNUAL INTEGRITY TEST(0.1 GPM) ❑ 12 ANNUAL INTEGRITY TEST(0.1 GPC) <br /> SUCTION/GRAVITY SYSTEM. SUCTION/GRAVITY SYSTEM <br /> ❑ 13. CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS ❑ 13. CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS <br /> EMERGENCY GENERATORS ONLY(Check aft that apply) EMERGENCY GENERATORS ONLY(Check all that apply) <br /> ❑ 14. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF-AUDIBLE AND ❑ 14. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF+AUDIBLE AND VISUAL <br /> VISUAL ALARMS ALARMS <br /> ❑ 15 AUTOMATIC LINE LEAK DETECTOR(3.0 GPM TEST)WITHOUT FLOW SHUT OFF OR ❑ 15. AUTOMATIC LINE LEAK DETECTOR(3.0 GPM TEST) <br /> RESTRICTION <br /> ❑ 18. ANNUAL INTEGRITY TEST(0.1 GPH) ❑ 16. ANNUAL INTEGRITY TEST(0.1 GPM) <br /> ❑ 17. DAILY VISUAL CHECK ❑ 17. DAILY VISUAL CHECK <br /> VIIL DISPENSER CONTAINMENT <br /> DISPENSER CONTAINMENT ❑ 1. FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE ❑ 4. DAILY VISUAL CHECK <br /> DATE INSTALLED ❑ 2. CONTINUOUS DISPENSER PAN SENSOR+AUDIBLE AND VISUAL ALARMS ❑ S. TRENCH LINER/MONITORING <br /> ❑ 3. CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR DISPENSER+AUDIBLE AND VISUAL ALARMS ❑ 6. NONE <br /> IX.OWNER/OPERATOR SIGNATURE <br /> I CePoty that the information provided heroin is true and accurate to Me best of try,knowledge. <br /> SIGNATURE OF 0ANER/OPERATOR DATE <br /> NAME OF OWNER;OPERATOR(print) TITLE OF OWNER/OPERATOR <br /> Partnrt Number(For Iota!use only) Permit Approved(For local use only) V Permit Expiration Date(For local use only) <br /> G �7 / <br /> CUPAFORM(4/99) <br /> Formerly SWRCS Form B <br />