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►. f FROM JIM THORPE OIL, INC. • FAX NO. : 209 368-1851 • Dec. 20 0003:01PM P8 0 UNIFIED PROGPAM CONSOUDATV)FORM TANKS UNDERGROUND STORAGE TANKS -TA.NK PAGE 2 VI.PIPING CONSTRUCTION(Check all that a iy) P4.-of U,IDERGROUND PIPNG ABOVEGROUND PIPING SYSTEM TYPE .PRESSURE [12.SUCTION ❑3.GRAVITY 458 [11.PRESSURE ©Z. SUCTION ❑3,GRAVITY 419 CONSTRUCTION p i. LE WALL ❑3.LINED TRENCH Q W.OTHER 46o ❑1,SINGLE WALL ❑95.UNKNOWN 462 MANL'rnCTl1R£x _WUHL£WALL ❑95.UNKNOWN ❑2.DOUBLE WALL Q 99.OTHER MANUFACTURER 461 MANUFACTURER aha 0 1.BARE STEEL ❑6.FRP COMPATIIILE W/1007. SMTHANOL ❑1,BARE STEEL []6.FRP COMPATIBLE w/ID0%METHANOL ❑2,STAINLESS STEEL ❑7.GALVANIZED STEEL ❑Unknown ©2. STAINLESS STEEL ❑7.GALVANIZED STEEL ❑3.P TIC COMPATIBLE W/CONTENTS Q 99. Oilier [13. PLASTIC COMPATIBLE W/CONTENTS O B.FLEXIBLE(HDPE) ❑99. OTHER Mq'nBERGLASS ❑S,FLEXIBLE(HDPE) C)4- FIBERGLASS ❑9.CATHODIC PROTECTION ❑5.STEEL W/COATING ❑9.CATHODIC PROTECTION 464 ❑5. STEEL W/COATING ❑95.UNKNOWN 465 VII.PIPING LEAK DETECTION(Check all that i) A decor nm ofthe candor try n]�n he s�E n eeE to the!Deal a mcy.) UNDERGROUND PIPNG ABOVEGROUND PIPING SINGLE WALL PIPING +6 SINGLE WAIL PIPING 467 PRESSURIZED PIPING(Chak 41 chill Apply): PRESSURIZED PIPING(Check all that apply): ©1,ELECTRONIC LINE LEAK DETECTOR 3.0 CPH PEST-Wj3 AU l o f UMP SMU t ❑L ELECTRONIC LINE TEAK DETECTOR 3.0 GPH TEST W=AUTO PUMP OFF FOR LEAK,SYSTEM FAILURE.AND SYSTEM DISCONNECTION+ SHUT OFF FOR LEAK,SYSTEM FAILURE,AND SYSTEM DISCONNECTION+ AUDIBLE AND VISUAL ALARMS, AUDIBLE AND VISUAL ALARMS. ❑2,MONTrHLY 0.2 GPH TEST' ❑2. MONTHLY 0.2 GPH TEST ❑3.ANNUAL NTFGRITY TEST(O.IOPH) ❑3,ANNUAL INTEGRITY TEST(O.IGPH) [14, DAILY VISUAL CHECK CONVENTIONAL SUCTION SYSTEMS CONVENTIONAL SUCTION SYSTEMS(Check all that apply) ❑S.DAILY VISUAL MONITORING OF PUMPING SYSTEM+TFURNMAL PIPING ❑S, DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM NT£OkITY TEST(0.1 OPH) SAFE SUCTION SYSTEMS(NO VALUES 1N SELOW GROUNDPIPING): ❑6. TRIENNIAL Ir1TEORITY TEST(0.1 GPH) ❑7.SELF MONITORING SAFE SUCTION SYSTEMS(NO VALVES N BELO*GROUND PIPTNG)i GRAVITY FLOW ©7. SELF MONITORING ❑9.BIENNIAL INTEGRITY TEST(0,1 GPTO GRAVITY FLOW(check all that vviyy ❑S. DAILY VISUAL MONITORING ❑9, BIENNIAL INTEGRITY TEST(D.1 GPH) SECONDARILY CONTAINED PIPING SECONDARILY CONTAINED PIPING PRESSURIZED PIPING(Check all that appiy) PRESSURIZED PIPING(Check ail that appy). 10. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL 10. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL ALA AND(Chcdr one) ALARMS AND(L'hcok oft) a. All PUMP SHUT OFF WHEN A LEAK OCCURS ❑a AUTO PUMP SHUT OFF WHEN A LEAK OCCURS ❑b. ALTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM ❑b AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM DISCO.YNECTION DISCONNECTION ❑c. NO AUTO PUMP SHUT OFF ❑c NO AUTO PUMP SHUT OFF 'AUTOMATIC UNE LEAK DETFCTOR(3.0 GPH TEST)WITH FLOW SHUT OFF OR RESTRICTION ❑l 1. AUTOMATIC CFnK DETECTOR ❑12. ANNUAL INTEGRITY TEST(0.1 GPH) []12, ANNUAL INTEGRITY T95T(0.1 GPH) S -UCT `ION/GRAVITY SYSTEM SUCTION/GRAVITY SYSTEM se'CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS ❑13• CONTINUOUS SUMP SENSOR•AUDIBLE AND VISUAL ALARMS EMERGENCY GENERATORS ONLY(Check all lho apply) E,MERGHNCY GE,IERLTORS ONLY(check An that apply) 14. CON'TINVOUS SUMP SENSOR WITHT AUTO PUMP SHUTOFF [7 14, CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF _,,-AUDIBLE AND VISUAL ALARMS AUDIBLE AND VISUAL ALARMS 5. AUTOMATIC LTNE LPAK OF,TBCTOR(3.0 GPH TFST)AaNOUT FLOW (]15. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST) SHLT OFF OR RESTRICTION [�16.ANNUAL INTEGRITY TEST(0,1 GPH) ❑16.ANNUAL INTEGRITY TEST(O.I GPH) []17. DAILY VISUAL CHECK IJ 17, DAILY VISUAL CHECK VITT.DISPENSER CONTAINMENT Ie- DISPE,,,ISFR CONTAINMENT ❑I.FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE 06 DAILY VISUAL CHECK DATE TNSTA(.LF,D 468 ❑2 CONTINUOUS DISPENSER PAN SENSOR+AUDIBLE AND VISUAL ALARMS ❑S.TRENCH LINER/MONITORING ❑3.CONTINUOUS DISPENSER PAN SENSOR 2M AUTO SHUT OFF FOR DISPENSER+AUDIBLE AND VISUAL ALARMS ❑6.NONE a69 DL OWNER/OPERATOR SIGNATURE I ecntfy that the m1b tion pro ' he eia i,A'= y � IGNAMR ERATO ATE 470 NAN 0t 0 O t) 471 F OFOWN£ P 70 Pe,mn Number('ae"ule only) F 413 Pennh Approved(Fot local tmo only) 474 Permil Expiation Dace(For local use only) 375 UPCF(12/99 revised) . . Formerly SWRGS Form 11