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'v UNIFIED PROGRAM CONSOLIDATED FORM TANKS UNDERGROUND STORAGE TANKS -TANK PAGE 2 VI.PIPING CONSTRUCTION(Check ad that appy) Me of UNDERGROUND PIPING ABOVEGROUND PIPING SYSTEM TYPE 1. PRESSURE ❑ 2. SUCTION ❑ 3. GRAVITY ❑ 1. PRESSURE ❑ 2. SUCTION ❑ 3. GRAVITY CONSTRUCTION/ ❑ 1. SINGLE WALL ❑ 3. LINED TRENCH ❑99. OTHER ❑ 1. SINGLE WALL ❑95. UNKNOWN MANUFACTURER DOUBLE WALL ❑95. UNKNOWN MANUFACTURER ❑ 2. DOUBLE WALL ❑99. OTHER MANUFACTURER ❑ 1.BARE STEEL ❑ 6. FRP COMPATIBLE W/100%METHANOL ❑ 1. BARE STEEL MATERIALS AND ❑ 2. STAINLESS STEEL ❑ 7.GALVANIZED STEEL ❑ 6. FRP COMPATIBLE L 100%METHANOL CORROSION ❑ 2. STAINLESS STEEL ❑ 7. GALVANIZED STEEL PROTECTION ❑ 3. PLASTIC COMPATIBLE WITH CONTENTS ❑95. UNKNOWN ❑ 3. PLASTIC COMPATIBLE WITH CONTENTS ❑ 8. FLEXIBLE(HOPE) ❑99. OTHER pfr4. FIBERGLASS ❑ 8. FLEXIBLE(HDPE) ❑99. OTHER ❑ 4. FIBERGLASS ❑ 9. CATHODIC PROTECTION ❑ 5 STEEL W/COATING ❑ 9. CATHODIC PROTECTION ❑ 5. STEEL W/COATING 1195. UNKNOWN VII.PIPING LEAK DETECTION(Check ad that appy) UNDERGROUND PIPING SINGLE WALL PIPING ABOVEGROUNOF I IPING PRESSURIZED PIPING(Check all that appy): PRESSURIZED PIPING(Check ad that aPPNI SINGLE WALL PIPING ❑ 1. ELECTRONIC UNE LEAK DETECTOR 3.0 GPM TEST WITH 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 FA ALARMS ILURE.AND SYSTEM DISCONNECTION;AUDIBLE AND VISUAL 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. DAILY VISUAL CHECK CONVENTIONAL SUCTION SYSTEMS CONVENTIONAL SUCTION SYSTEMS(Check alt that appy): ❑ 5 DAILY VISUAL MONITORING OF PUMPING SYSTEM-TRIENNIAL PIPING INTEGRI7Y115. DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM TEST(0 t GPM) ❑ 6. TRIENNIAL INTEGRITY TEST(0.1 GPM) SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): 7. SELF MONITORING SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): ❑ 7. SELF MONITORING GRAVITY FLOW GRAVITY FLOW(Check a.11 that appy); ❑ 9. BIENNIALINTEGRITY TEST(0 7 GPM) � ❑ B. DAILY VISUAL MONITORING ❑ 9. BIENNIAL INTEGRITY TEST(0.1 GPM) SECONDARILY CONTAINED PIPING PRESSURIZED PIPING(Check all that apply): SECONDARILY CONTAINED PIPING 10. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIPRESSURIZED PIPING(Check all that appy): BLE AND VISUAL ALARMS AND (Check one) 10.CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL ALARMS AND(check one) ❑ a AUTO PUMP SHUT OFF AMEN A LEAK OCCURS ❑ a. AUTO PUMP SHUT OFF WHEN A LEAK OCCURS AO.SCONNECTIONUTO PUMP SHUT OFF FOR LEAKS.SYSTEM FAILURE AND SYSTEM ❑ b. AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM DISCONNECTION ❑ c. NO AUTO PUMP SHUT OFF ❑ c. NO AUTO PUMP SMUT OFF ❑ 11 AUTOMATIC RESTRICTION LEAK DETECTOR(3.0 GPM TEST)WITH FLOW SHUT OFF OR ❑ 11. AUTOMATIC LEAK DETECTOR ❑ 12. ANNUAL INTEGRITY TEST(C 1 GPM) ❑ 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+AUDIBLE AND VISUAL ALARMS EMERGENCY GENERATORS ONLY(Check all that apply) ' C114. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF+AUDIBLE AND EMERGENCY GENERATORS ONLY(Check ad that appty) VISUAL ALARMS ❑ 14. CONTINUOUS SUMP SENSOR WITHOUT ALTO PUMP SHUT OFF+AUDIBLE AND VISUAL ❑ 15. AUTOMATIC LINE LEAK DETECTOR(3.0 GPM TEST)WITHOUT FLOW SHUT OFF OR ALARMS RESTRICTiOtt ❑.15. AUTOMATIC LINE LEAK DETECTOR(3.0 GPM TEST) ❑ 16.ANNUAL INTEGRITY TEST(0.1 GPM) ❑ 16. ANNUAL INTEGRITY TEST(0.1 GPM) ❑ 17. DAILY VISUAL CHECK ❑ 17. DAILY VISUAL CHECK - VHL DISPENSER CONTAINMENT DISPENSER CONTAINMENT ❑ 1. FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE DATE INSTALL ❑ 2.CONTINUOUS DISPENSER PAN SENSOR+AUDIBLE AND VISUAL ALARMS ❑ 4. DAILY VISUAL CHECK (� ❑ 5. TRENCH LINER/MONITORING . CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR DISPENSER+AUDIBLE AND VISUAL ALARMS ❑8. NONE IX.OWNER/OPERATOR SIGNATURE I Cerufy that the inforrawn Provided herein is true and accurat to a hest of my knowledge. SIGNATURE OF OWNER/OPERATOR ` DATE c� �o god NAME OF GWTJER/OPERATOR(print) TITLE OF O R,OPERA R S l"IzN11 G SIA Pamd Number(For local use only) Permit Approved or at use ony) Pewit Expiration Date(Forfccaf use only) CUPAFORM(4/99) Formerly SWRCS Form B