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Jan 10 03 04: 47p Vie Brown (2 461-6342 p. 1 V UNIFIED PROGRAM CONSOLIDATED FORM J3 TANKS UNDERGROUND STORAGE TANKS-TANK PAGE 2 Pace of VL PIPING CONSTRUCTION chat all that apply) UNDERGROUND PIPING ABOVEGROUNDPIPIIJG SYSTEM TYPE ®1.PRESSURE ❑2.SUCTION ❑3.GRANgTY 458. 0 1.PRESSURE 0 2.SUCTION 113.GRAVITY 459. CONSTRUCTION/ ❑1.SINGLE WALL ❑3.LINED TRENCH ❑99.OTHER ❑1.SINGLE WALL ❑95.UNKNOWN 462 MANUFACTURER G 2.DOUBLE WALL ❑95.UNKNOWN ❑2.DOUBLE WALL 0 99.OTHER MANUFACTURER � . �, C) M l -r J461. MANUFACTURER 463' ❑1.BARE STLEL ❑6.FRP COMPATIBLE W/100"/e MfiTHANOL ❑1.BARE STEEL ❑6.FRP COMPATIBLE W1100%METHANOL 0 2.STAINLESS STEEL 0 7.GALVANIZED STL£L ❑2.STAINLESS STEEL ❑7.GALVANIZED STEEL 0 3.PLASTIC COMPATIBLE WITH CONTENTS ❑95.UNKNOWN ❑3.PLASTIC COMPATIBLE W/CONTENTS 0 S.FTE1 lBLE(HDPE) 0 99.OTHER 0 4.FIBERGLASS 0 8.FLEMLE(III)PE) [:199.OTHER C]4.FIBERGLASS ❑9.CATHODIC PROTECTION 465 ❑5.S-WEL w/COATING ❑9.CATHODIC PROTECTION 464. ❑5.ST1•EL W/COATING ❑95.UNKNOWN VIL PIPING LEAK DETECTION(Chwk-11um- (Aorthemonirory abaABOVEGROUND PIPINbe sLihmead to dw Local G) UNDERGROUND PIPING SINGLE WALL PIPING 466. SINGLE WALL PIPING 467. PRESSURI7FD PIPING(Cliock all that apply): PRESSURIZ.BD PIPING(Chuck all that apply). ❑I OFFLINE �$ MFGPH TEST RM AUTO PUMP I ❑1 � �SHLOOSYSEMFAIE LEAK JIE, NSYS- DCC�- CIO S U7 OFI p LAL, yS RARE AND SYSTEM DISCONNECTION FT SN II +AUDIBLE AND VISUAL ALARMS. +AUDIBLE AND VISUAL ALARMS. V 0 2. MONTHLY 0.2 GPH TEST j 02. MONTHLY 02 GPH TEST 1I ❑3. ANNUAL INTEGRITY TEST(0.1 GPH) i! ❑3. ANNUAL INTEGRITY QST(OA GPn7 I 04. DAu.Y VISUAL a"U-IECK i CONVENMONAL SUCTION SYSTEMS CONVENTIONAL SUCTION SYSTEMS(Check all that apply) .[35. DAILY VISUAL MONITORING OF PUMPING SYSTEM+-TRIENNIA_PIPING [35. DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM INTEGRITY TEST(0.1 GPA) SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): [:36. TRIEDIIiIAI.INTEGRITYIEST(D.1 GPH) SAFE SYS tEMS(NO VALVES INBELOW GROUND PQPING) 0 7 SELF MONITORING GRAVITY FLOW ❑7. SELF MONITORING ❑9. BIENNIAL INnGRITY TESL(0.1 GPIl) GRAVITY FLOW(Check all that apply): Os. DAILY VISUAL MONITORING 0 9. BIENNIAT.INTEGRITY TEST(0.1 GPI SECONDARILY CONTAINED PIPING SECONDARILY CONTAINED PIPING PRESSURIZED PIPING(Check all that apply): PRESSURIZED PIPING(Check all that apply): 10. CONTINUOUS TURBINE SUMP SENSOR WITIi AUDIBLE AND VISUAL 10. CONTINUOUS TURBINE SUMP SENSOR wrrii AUDIBLE AND VISUAL ALARMS AND(Cheek one) ALARMS AND(Check one) ®a.AUTO PUMP SMUT OFF WHEN A LEAK OCCURS 0 a. AUTO PUMP SHUT OFF WHEN A LEAK OCCURS ®b.AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM ■b.AUTO PUMP ON OFF FOR LEAKS,SYSTEM FAILURE AND SYSTTiM DISCONNECTION ❑c. NO AUTO PUMP SInT OFF ❑c. NO AUTO PUMP SHUT OFF Ell, AUIQMATIC LINE LEAK DETECTOR(3.0 GPH TEST)R!I: FLOW SHUT ®11.AUTOMATIC LEAK DETECTOR OFF OR RESTRICTION E]12. ANNUAL INCEGRIT'Y TEST(0.1 GPH) ❑12.ANNUAL INTEGRITY TEST(0.1 GPH) SUCTION/GRAVITY SYSTEM SUCIIJOIN GRJAVTIY SYSTEM ❑13. CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS O 13. CONTINIKMS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS EMERGENCY GENERATORS ONLY(Cheri all that apply) EMERGENCY GENERATORS ONLY(Chock all that apply) [314. CONTINUOUS SUMP SENSOR WTTHOUT AUTO PUMP SHUT OFF [114.CONTINUOUS SUMP SENSOR i(K..9 AUTO PUMP SHUT OFF AUDIBLE AND VISUAL ALARMS AUDIBLE AND VISUAL ALARMS [115, AUTOMATIC LINE LEAK DETECTOR (3.0 GPH TEST) WLTIQL FLOW 015 AUTOMATIC LINE LEAKDETECfOR(3.0GPH TEST) SIM OFF Olt RESTRICTION 016. ANNUAL INTEGRITY TEST(0.1 GPH) El 16-ANNUAL INTEGRITY TEST(0,i GPH) ❑17. DATLY VISUAL CHECK ❑17.DAILY VISUAL CHECK VIII DISPENSER CONTAINMENT DISPENSER CONTAIIv'MENT 46s. ❑1. FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE ❑4. DAILY VISUAL CHECK 469, DATE INSTALLED N2. CONTINUOUS DISPENSER PAN SENSOR+-AUDIBLE AND VISUAL ALARMS 135. TRENCH/LIN£R MONITORING ❑3. CONTINUOUS DISPI, 'R PAN SENSOR WITH AUTO SHUT OFF FOR 0 6. NONE DISPENSER r AUDIBLE AND VISUAL ALARMS IX.OWNF.R/OPERATOR SIGNATURE I certify that the information provided herein is two and accurate to the best of my knowledge. 470. SIGNAT7F 0 OPE E. ,-G ar_. NAME OWNER/ ERAT ' 'ra): TITLE OFOWNER/OPERATOR G,� e/t e a,t` 1 ati use only) 475. P Nuse it umber(Agency e only) 473. ermit Approved By(Agency use only) 474. PesmA Expi on Date(Agrncy