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Ja�0. 10 03 04: 47p Vie Brown (2C$ 461 -63 2 p. 3 UNIFIED PROGRAM CONSOLIDATED FORM TANKS UNDERGROUND STORAGE TANKS-TANK PAGE 2 Pape'! of VL PIPING CONSTRUCTION(Cho*all Nat a ) UNDERGROUND PIPING ABOVEGROUND PIPING Z SUCTION O 3.GRAVITY 452. ❑1.PRESSURE ❑2.SUCTION 113.GRAVITY �• SYSTEM TYPE JM 1.PRESSURE ❑ 462. CONS IRUCITON/ [11.SINGLE WALL ❑3.LINED TRENCH O 99-UTHFR 460- ❑1.SINGLE WALL ❑95.LIKK TOWN MANUFACTURER2 DOUBLE WALL ❑95.UNKNOWN r]2"DOUBLE WALL ❑99.OTHFA IN .1. MANUFACTURER 467. MANUFACTURER A Q :T ❑6.FRP CDMParIBLE w/lona,:-ETHANoI ❑1.BARE STEEL [16.FRP COMPATIBLE'W1IOMI-METHANOL ❑1.RARE STEEL. 7.GALVANIZED STEEL ❑2 STAINLESS STEEL [17,GALVANIZED STEEL ❑2.STAINLESS STMbL ❑3.PLASTIC COMPATIBLE GCONTENTS ❑95.UNKNOWN ❑3.PLASTIC COMPATIBLE W/CONTENTS ❑8,rLE)QBLE(H)PE) [399.OTHER ❑9.CATHODIC PROTECTION 0 4.FIBERGLASS EI8.FLEXIBLE(HDPE) ❑99.OTIiER 4Ga. ❑5.STEEL W/COATING ❑95_UNKNOWN 465. ❑5.STEEL.W/COATING ❑9.CATHODIC PROTHCTION VII.PER-c-, DPTEcrroi�I(chick au Nat a y(A 'on of the ow,ri shall be snlmittcd to Ne local al;�vJ 1TNDI:RGROLRvD?PING 4r,6. PIPING 467 466. SINGLE WALL PIPING SINGLE WALL PIPING PRESSURIZED PIPING(Check all that ably). PRESSURIZED PIPING(Check all that apply): ❑1. ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST� AUTO PUMP ❑1. ELFCTRONICLINELEAK DETECTOR i0 GPIITEST WV111ALTOPUMP SHUT-OFF FOR LEAK,SYSTEM FAILURE.AND SYSTEM-DISCONNECTION +IAUDIOFFFORLFAX BLE AND VISUALCALARMSTE �r r� 4*IDSYSI EM DISC(7Nt4ECTIOPF +AUDIBLE AND VISUAL ALARMS" 1 ❑2. MONTfII.Y 0.2 GPH TEST ❑2" MONTHLY 0.2 GPHTEST [13- ANNUAL IN-MGRn Y TEST(0.1 GPH) ❑s. ANNUAL INTEGRa'I'i i ES (0-1 GTn/ J E34. DAILY V ISUAL CHECK CONVEN'110NAL SUCTION SYSTEMS CONVENTIONAL SUCTION SYSTEMS(Check all th2d:PpIY) [is. DAILY VISUAL MONITORING OF PUMPING SYSTEM+TRIENNIAL PIPING [35. DAILY VISUAL MOWTORING OF PIPING AND PUMPING SY ti TEM INTEGRITY TEST(0.1 GPH) SAFE SUCIIONSYSTEMS(NO VALVES INBELOW GROU14DPIPING): ❑6. YRWJ4NIALINTEGRTI'YTrsT(o.IGPIO ❑7" SELFMONTTORING SAFE SUCTION SYSTEMS(NO VALVES U4BELOW(ROUNDPIPING): GRAVTIY FLOW [17. SELF MONITORING ❑9. BIENNIAL IITTEGRITY TEST(0.1 GPM GRAVITY FLOW(Check all them apply): ❑& DAILY VISUAL MONITORING ❑9. BIENNIAL INTEGRITY TEST(0"]GPM SECONDARILY CONTAINED PIPING SECONDARILY CONTAINED PIPING PRESSURIZED PIPING(Che&all that apply): PRESSURIZED PIPING(Check all that apply): 10, CONTINUOUS TURBINE SUMP SENSOR t�I AUDIBLE AND VISUAL 10. CONTINUOUS TU INE)SUMP SENSOR MT-H AUDIBLE AND VISUAL AND(Check one) ALARMS AND(Check E a AUTO PUMP SHUT OFF WHEN A IEAK OCCURS ❑a AUTO PUMP SHUT OFF WHEN A LEAK OCCURS ■b.AUTO PUMP SHUT OFF FOR LEAILS,SYSTEM FAILURE AND SYSTEM M b.AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM DISCONNECTION DISCONNECTION C]c. NO AUTO PUMP SHUT OFF ❑c. NO AUTO PUMP SHUT OFF ®ll. AUTOMATICLINE LEAKDETECTOR(3.0 GPIITEST)WITFIFLOWSHUT X11 AUTOMATIC LEAK DETECTOR OFF OR RESTRICTION C112. ANNUAL Ili.-MGRITY TEST(0.1 GPM ❑12-ANNUAL TNTLCIiITY TEST(OMI GPH) SUCTION/GRAVITY SYSTEM SUCTIOMGRAVITY SYSTEM [113. CONTINUOUS SUMI,SENSOR+AUDIBLE AND VISUAL ALARMS N 13,CONTD41MS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS EMERGENCY GENERATORS ONLY(Check all tha(apply) EMERGENCY GENERATORS ONLY(Check all that apply) ❑ MP 14. CONTINUOUS SUSENSOR Nk=- AUTO PUMP SHUT OFF ❑l4. AUDIBLE ANDCONTINUOUS VISUAL ALARMS SUNe SENSOR L��AUTO PUMP SHUT OFF AUDIBLE AND VISUAL ALARMS ❑L5. AUTOMATIC LINE LEAK DETECTOR (3.0 GPH TEST) R7TI40LTT FLOW ❑15_AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST) SHUT OFF OR RESTRICTION [3 l6. ANNUAL INTEGRITY TESL(O.l GPIO O 16.ANNUAL INTEGRITY TEST(0.i GPM ❑17. DAILY VISUAL CHECK El17.DAILY VISUAL CHECK VIII.DISPENSER CONTAINMENT DISPENSER CONfAIN4h4L•NT 462. ❑1. FLOAT'MECHANISM THAT SHUTS OFF SHEAR VALVE [:14. DAILY VISUAL CHECK 469. DATE INSTALLED ®2- CONTINUOUS DISPHNSEP,PAN SENSOR+AUDIBLE AND VISUAL ALARMS (15. TRENCHUNL•R MONITORING 03. CONTINUOUS DISPENSER PAN SENSOR WM AUTO SHUT OFF FOR 06. NONE DISPENSER+AUDIBLE AND VISUAL ALARMS M OWNE Z/OPER4TOR SIGNATURE I certify that the information provided herein is true and acetaate to the best of mY lmovAedge. 470 SIGNAI OFA INNER/ ER44 DATE: :` C2 472 TITLE OF OWNERIOPERATOR N OF OWNER/OPERK')' ennit Number(Agency tue ady) 473. Permit Appy By(Agency use only) 474. 1 Permit Exp mun Dace(Agency tie on1Y) 475.