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i Jan 13 03 12: 06p C v ie Brown (2 461 -6342 p. 3 II�3Ia� UNIFIED PROGRAM CONSOLIDATED FORM TANKS UNDERGROUND STORAGE TANKS-TANK PAGE 2 Ya�c of VL PIPING CONSTRUCTIONCCeaJ all that apply) UNDERGROUND PIPING ABOVEGROU1,MNPING SYSTEM TYPE 4M 1.PRESSURE D 2.SUCTION ❑3.GRAVITY 458, 0 t,PRESSURE 0 2.SUCTION 113-GRAVITY c59. CONSTRUCnON/ ❑1.SINGLE WALL ❑3.LINED TRENCH ❑99.OTtTR 460. ❑1.SINGLE WALL 0 95.UNKNOWN 462. MANUFACTURER IN 2.DOUBLE WAIL 0 95.UNKNOWN ❑2.AOUD[£WALL ❑99,OTl3F,3t MANUFACTURER n , OS>/V-) r TH 461. MANUFACTURER 463. ❑I.BARE STEEL. ❑6.FRP COMPATIBLE W1100%METHANOL 0 1.BARE STEEL ❑6.FRP COMPATIBLE WI100°/,METHANOL ❑2.STAINLESS STEEL 0 7,GALVANEZED STEEL 0 2.STAINLESS STEEL (17.GALVAM2kD STEEL. 0 3.PLASTIC COMPATIBLE WITH CONTENT'S ❑95.UNKNOWN 0 3.PLASTIC COMPATIBLE W/CONTENTS ❑&FLE BLz(IMPE) 1199.OTHER 194,kIBERGLASS ❑8.FLEXIBLE(HDPE) 0 99.OTHER 0 4.FML•RGLASS 0 9.CATHODIC PROTECTION []5.STEEL W/COATING 0 9_CATIIODIC PROTECTION 464. 115.STEEL W/COATING ❑95.UNKNOWN 465. VIL PIPING LEAK DETECTION(chec);all that apply)(A 6-of the�Awing p t sbau be submiu d t.the local aFcwy: UNDERGROUND PIPING ABOVEGROUND PIPING SINGLE WALL PIPING 466. SINGLE WALT.PIPING 4W. PR£.SSURTZED PIPING(Check.all that aP14y): PRESSURM D PIPING(Check all that apply): ❑1. EL.ECTRONJC LINE LEAK DETECTOR 3.0 GPH TEST W[TFT AUTO PUMP 01. ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TfSr wroj AUTO pump SHUT-OFF FOR LEAK,SYSTEM FAILURE,AW-D SYSTEM DISCONNECTION SIIU'T'OFF FOR LACE SYSTEMF CnZE.eT1DcYSTEM DLSCONNEC-ON i +AUDIBLE AND VISUAL ALARMS. I +AUDIBLE AND VISUAL ALARMS. t [12. MONTHLY 0.2 GPH TEST I 02- MONTHLY 0.2 GPli TTST t ❑3. ANNUAL IISrliGRITY TEST(0.1 GPH) j 03. ANNUAL I TEG"Rc'Tt-1 ST(G.i Cn-xr, t 104. DAILY VISUAL CHECK CONVENTIONAL SUCT!ON SYSTEMS CONVENTIONAL SUCTION SYSTEMS(Check all that reply) 05. DAILY VISUAL.MONITORING OF PUMPING SYSTEM+TRTENNIAI.PIPING INTEGRITY TEST(0.I GPM ❑S. DAILY VISUAL MOAIITORWG OF PIPING AND PUMPING SYSTEM SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING)- ❑6. TRIENNIAL INTEGRITY TEST(O,i GPit) [17. SELF MONITORING SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): GRAVITY FLOW] ❑7. SELF MONITORING [19. BIENNIAL INTEGRITY TEST(0.1 GPH) GRAVITY PLOW(Cheek all that apply): ❑8. DAILY VISUAL MONITORING 09. BmNNIALINmGRITYTT:sT(o,JGPM SECONDARILY CONtiTA NED PIPING SECONDARILY CONTALN-M PIPING PRES,SURTZED PIPING(Check-all that apply): PRESSURIZED PIPING(Check 4 thm apply): t0. CONTINUOUS TURBINE SUMP SENSOR Mn AUDIBLE AND VISUAL 10. CONTINUOUS TURBINE SUMP SENSOR WTrIt AUDIBLE AND VISUAL ALARMS AND(Check one) ALARMS AND(Check one) ®a. AUTO PUMP ST;IUT OFF WHEN A LEAK OCCURS 0 a AUTO PUMP SHUT'OFF MIEN A LEAK OCCURS ®b.AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM 0 b.AUTO PUMP SHIFT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM, DISCONNECTION DISCONNECITON ❑c. NO AUTO PUMP SHUT OFF Oc. NO AUTO PUMP St'JUI OFF ®11. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)WPI FLOW SHUT OFF OR RESTRICTION ®Il_AUTOMATIC LEAK DETECTOR [112. ANNUALINTEGRITYTEST(0.I GPEj) 0l2.ANNUAL BITEGRITYTEST(0.1 GPH) SUCTIONIGRAVM SYSTEM SUCTIONIGRAVIIYSYST'EM ❑13. CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS N 13.CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS EMERGENCY GENERATORS ONLY(Choc all that apply) EMERGENCY GENERATORS ONLY(Check all that WAy) ❑14. CONTINUOUS SUMP SENSOR ML4 Tf AUTO PUMP SHUT OFF [114. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SENT OFF AUDIBLE AND VISUAL ALARMS AUDIBLE AND VISUAL ALARMS 015. AUTOMATIC LINE LEAK DETECTOR (3.0 GPII TEST) W71-YI01 FLOW SHUT OFF OR RESTRICTION 0 15.AUTOMATIC LINE LEAK DETECTOR(3.0 GPII TEST) 016. ANNUAL INTEGRITY TTST(0_i GPM) 0 16.ANNUAL INTEGRITY TEST(0.1 GPII) [317. DAILY VISUAL CiIECK 0 17.DAILY VISUAL CHECK, VIIL DISPL+NSFR CONTAINMENT DISPENSER CONTARNMENI 468, ❑L FLOAT MECHANTSM THAT SHUTS OFF SHEAR VALVE [14. DAILY VISUAL CHECK 469. DATE INSTALLED 82. CONTINUOUS DISPENSER PAN SENSOR+AUDIBLE,AND VISUAL ALARMS 0 5. T t1:?ICFLLINL•TL MONITORING [13. CONTINUOUS DISPENSER PAN SENSOR Vim✓TL{ AUTO SHUT OFF FOR [16, NONE DISPENSER,AUDIBLE AND VISUAL ALARMS M O WNER/OPER.TOR SIGNATURE I ceriify that the information provided herein is true and accurate lo the best of my knowledge, SI GNA OF PER+� �� DATE: 420. N OF OWNER/OPERAT Spgac)C l /c' f P / TITLE OP OWNER/OPERATOR: 4n f C J ! iZt 37, P. S 4 74 i ermit Number(Agency use only) 473. Permit Appr By(Agency use only) 474. 1 Permit Expiration Date(A,(racy use only) 475.