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UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANKS - TANK PAGE 2 TANKS I UNDERGROUND PIPING VI.PIPING CONSTRUCTION(Checkallth.a!appy) ^• , SYSTEM TYPE ABOVEGROUND PIPING PRESSURE 132. SUCTION ❑ 3. GRAVITY ❑ 1. PRESSURE MANUFACTURE ❑ 1. SINGLE VIALL ❑ J. LINED TRENCH ❑ 2. SUCTION ❑ 3. GRAVITY MANUFACTURER 2. DOUBLE MALL 1:195. UNK.VO'hN ❑93 OTHER ❑ 1. SINGLE WALL ❑ ❑95. 4t 2. DOUBLE WALL OTHER MANUFACTURER ❑99. OTHER MANUFACTURER 1.BARE STEEL ❑ 8. FRP COMPATIBLE NJ/104'.S M.THANOL MATERIALS AND ❑ 2. STAINLESS STEEL ❑ 1. BARE STEEL CORROSION ❑ 7.GALVANIZED STEEL ❑ 6. FRP COMPATIBLE W!10%METHANOL PROTECTION ❑ 3. PLASTIC COMPATIBLE WITH CONTENTS ❑ 2 STAINLESS STEEL ❑ 7.GALVANIZED STEEL ❑9� -.HER UNKNOWN ❑ J FUSTIC COMPATIBLE WITH CONTENTS ❑ S. FLEXIBLE(HDPE) ❑99. OTHER FIBERGLASS ❑ 6. FLEXIBLE(HOPE) ❑99 CTHER ❑ a. FIBERGLASS I 5. STEELW;COATING ❑ 9.CATHOLIC PROTECTION ❑ 9. CATHODIC PROTECTION ❑ S. STEEL W/COATING 1-195. UNKNOWN VII.PIPING LEAK DETECTION(Check all that appy) UNDERGROUND PIPING SINGLE WALL PIPING PRESSURIZED PIPING(Check all mat appy): ABOVEGROUND PIPING ❑ 1. ELECTRONIC UNE LEAK DETECTOR 3.0 GPM TEST W17M AUTO PUMP SHUT PRESSURIZED PIPING(Check all that a SINGLE WALL PIPING LEAK,SYSTEM FAILURE. S U OFF FOR ppy): LURE,AVO SYSTEM DISCONNECTION• ❑ 1. ELECTRONIC LINE LEAK DETECTOR 3.0 GPM TEST WITH AUTO PUMP SHUT OFF FOR LEAK, ALARMS AUDIBLE AND VISL'A_ SYSTEM FAILURE.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) ❑ J. ANNUAL INTEGRITY TEST(0.1 GPM) CONVENTIONAL SUCTION SYSTEMS 4. DAILY VISUAL CHECK C15 DAILY VISUAL AIONITQRINiG OF PUMPING SYSTEM. CONVENTIONAL SUCTION SYSTEMS(Check a#that apply): TEST(0 1 GPM) TR;ENIttIAL PIPING IN7EGR.'i ❑ 5. DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING)- ❑ 8 TRIENNIAL INTEGRITY TEST(0.1 GPM) ❑ 7. $ELF MONITORING SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): GRAVITY FLOW - ❑ 7. SELF MONITORING ❑ 9. BIENNIAL INTEGRITY TEST(0 1 GPM) GRAVITY FLOW(Check an mat apply): ❑ 8. DAILY VISUAL MONITORING SECONDARILY CONTAINED PIPING 119 131ENNIAL INTEGRITY TEST(0.1 GPM) PRESSURIZED PIPING(Check aatnat apply): PRESSURIZED PIPING(Check all that a SECONDARILY CONTAINED PIPING 10 CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL ALARMS A%:) ppy)' I (Cr.xk one) ❑ a AUTO PUMP SHUT CFF'AMEN A LEAK OCCURS 10.CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL ALARMS AND(check one) ^ AUTO PUMP SHUT OFF FOR LEAKS.SYSTEM FAILURE AND SYSTEM 11a.AUTO PUMP SHUT OFF VMEN A LEAK OCCURS DISCONNECTION ❑ E NO AUTO PUMP SHUT OFF ❑ AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM OISCONNCCTION ❑ 11 AUTOMATIC LINE LEAP,DETECTOR(J.0 GPM TES HATH F W ❑ C. NO AUTO PUMP SHUT OFF RESTRICTION T) LO SHUT OFF OR ❑ 12 ANNUAL INTEGRITY TEST(C 1 GPM) ❑ 11 AUTOMATIC LEAK DETECTOR i SUCrION/GRAVITY SYSTE ❑ 12.ANNUAL INTEGRITY TEST(0.1 GPM) M: ❑ 13 CON TINUGUS SUMP SENSOR•AUDIBLE AND VISUAL ALARMS SUCTIOWGRAVITY SYSTEM; ❑ EMERGENCY GENERATORS ONLY(Check as mat appy) 13 CONTINUOUS SUMP SENSOR-AUDIBLE AND VISUAL ALARMS I ❑ 14. CONTINUOUS SUMP SENSOR WITHOUT AUTO DUMP$HUT OFF+gU019LE AND EMERGENCY GENERATORS ONLY(Check as that apply) VISUAL ALARMS ❑ 14. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF+AUDIBLE AND VISUAL ❑ 15. AUTOMATIC UNE LEAK DETECTOR(3.0 GPM TEST)VATHOUT FLOW SHUT OFF OR ALARMS RESTRICTION ❑ 15.AUTOMATIC LINE LEAK DETECTOR(3.0 GPM TEST) ❑ 16.ANNUAL INTEGRITY TEST at GPM) ❑ 17.DAILY VISUAL CHECK ❑ 16.ANNUAL INTEGRITY TEST(0.1 GPM) ❑ 17. DAILY VISUAL CHECK YHk DISPENSER CONTAINMENT DISPENSER CONTAINMENT 131. FLOAT MECHANISM THAT SHUTS OFF SHEAR OATS INEJ� VALVES : ❑ 13 4. OAILY VISUAL CHECK 2.CONTINUOUS DISPENSER PAN SENSOR.AUDIBLE AND VISUAL ALARMS 11 S. TRENC 3 CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR DISPENSER•AUOIBLE AND VISUAL ALARMS 116. NONE M UNER/MONITORING I cartify that the information i d herein is true and aoa rate to me oast of my Anowte X•OWNERIOPERATOR SIGNATURE SIGNATUP.E OF OWNER/0 TOR TOR DATE NAME OF G4eNE1LOPERi (prtntj `` TITLEOFOWNEROPE,4A R Permit Num.er(por/oc4/use only) Permit APPmo sd(Forloca/use only) Permit Expiration Date(Forlxal use onry) JPAFORM(4/99)