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'PROGRAM CONSOLIDATED <br /> TANK <br /> UNDERGROUND STORAGE TANKS- TANK PAGE 2 <br /> VL PIPING CONSTRUCTION anthatapply) Page-of- <br /> UNDERGROUND PIPING ABOVEGROUND PIPING <br /> SYSTEM TYPE 0 1.PRESSURE 0 2.SUCTION 0 3.GRAVITY 458 0 1.PRESSURE 0 2. SUCTION 0 3.GRAVITY 459 <br /> CONSTRUCTION 0 1.SINGLE WALL 0 3.LINED TRENCH 0 99.OTHER 0 1.SINGLE WALL 0 95.UNKNOWN 462 <br /> MANUFACTURER 0 2.DOUBLE WALL 0 95.UNKNOWN 0 2.DOUBLE WALL 0 99.OTHER <br /> MANUFACTURER Unknown 461 MANUFACTURER 463 <br /> 0 1.BARE STEEL 0 6.FRP COMPATIBLE W1100% METHANOL 0 1.BARE STEEL 0 6.FRP COMPATIBLE W110M METHANOL <br /> 0 2-STAR41ESS STEEL 0 7.GALVANIZED STEEL 10 Uknown 0 2. STAINLESS STEEL 0 7.GALVANIZED STEEL <br /> 0 3.PLASTIC COMPATIBLE W/CONTENTS 0 99. Other 0 3. PLASTIC COMPATIBLE W/CONTENTS 0 9.FLEXIBLE(HDPE) 1199. OTHER <br /> 0 4.FIBERGLASS 0 8.FLEXIBLE(HDPE) 0 4. FIBERGLASS 0 9.CATHODIC PROTECTION <br /> 0 5.STEEL WICOATING 0 9.CATHODIC PROTECTION 464 0 5. STEEL W/COATING [I 95.UNKNOWN 465 <br /> VII.PIPING LEAK DETECrION(check an that apply)(A descaiptioat ofthcmorjitermgprog=shaUbesab=ttedtolhekcal Agmcy.) <br /> UNDERGROUND PIPING ABOVEGROUND PIPING <br /> SINGLE WALL PIPING 466 SINGLE WALL PIPING 467 <br /> PRESSURIZED PIPING(Check all that apply): PRESSURIZED PIPING(Check all that apply): <br /> 0 1.ELECTRONIC,LINE LEAK DETECTOR 3.0 GpH TEST WITH AUTO PUMP sHur 0 1. ELECTRONIC LINE IEAKDETECTOR 3.0 CPH TEST W IlTI AUTO PUMP <br /> OFF FOR LEAK,SYSTEM FAILURE,AND SYSTEM DISCONNECTION+ SHUT OFF FOR LEAK,SYSTEM FAILURE,AND SYSTEM DISCONNECTION+ <br /> AUDIBLE AND VISUAL ALARMS. AUDIBLE AND VISUAL ALARMS. <br /> 0 2.MONTHLY 0.2 GPHTEST 0 2. MONTHLY 0.2 GPHTEST <br /> 0 3.ANNUAL lNrE(WrY TEST(0-IGPM 0 3.ANNUAL INTEGRITY TEST(0-1GPM <br /> 0 4.DAILY VISUAL CHECK <br /> CONVENTIONAL SUCTION SYSTEMS CONVENTIONAL SUCTION SYSTEMS(Check all that apply) <br /> 0 5.DAILY VISUAL MONITORING OF PUMPING-SYSTEM+TRIENNIAL PIPING 05. DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM <br /> INTEGRrrYTEST(0.1(Pff) <br /> SAFE SUCTION SYSIT243(NO VALUES IN BELOW GROUNDPIPING): [16.TRIENNIAL mrEcuff TEST(0.1 cpM <br /> 0 7.SELF MONITORING SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): <br /> GRAVITY FLOW ®7. SELF MONITORING <br /> 9.BIENNIAL INTEGRITY TEST(0.1 GPM GRAVITY FLOW(Check all that apply): <br /> [3 s. DAILY VISUAL MONITORING <br /> El 9. BIENNIAL INTEGRITY TEST(o.i(PH) <br /> SECONDARILY CONTAINED PIPING SECONDARILY CONTAINED PIPING <br /> PRESSURIZED PIPING(Check all that apply): PRESSURIZED PIPING(Check all that apply): <br /> 10. CONTINUOUS TURBINE SUMP SENSOR AUDIBLE AND VISUAL 10. CONTINUOUS TURBINE SUMI?SENSOR,WITH AUDIBLE AND VISUAL <br /> ALARMS AND(Check one) ALARMS AND(Check one) <br /> ❑a. AUTO PUMP SHUT OFF WHEN A LEAK OCCURS 0 a Auro PUMP SHUT OFF WHEN A LEAK OCCURS <br /> ❑b. AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM 0 b AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM <br /> DISCONNECTION DISCONNECTION <br /> Oc. No Auro PUMP SHUT OFF Oc NO AUTO PUMI?SHUT OFF <br /> 0 11. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)WITH FLOW SHUT 13 11. AUTOMATIC LEAK DETECTOR <br /> OFF OR RESTRICTION <br /> 0 12. ANNUAL DaTmrff TEST(0.1 GPM 0 12. ANNUAL mrEGRITY TEST(o.i GPM <br /> SUCTION/GRAVITY SYSTEM SUCTIONIGRAVITY SYSTEM <br /> 10 13. CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARM 0 13. CONTINUOUS SUMP SENSOR+AUDIBLE, AND VISUAL ALARMS <br /> EMERGENCY GENERATORS ONLY(Check allfhat apply} EMERGENCY GENERATORS ONLY(Check all that apply) <br /> 0 14. CONTINUOUS SUMP SENSOR wrMouT AUTO PUMP SHUT OFF 0 14. CONTINUOUS sump SENSOR wrmour Auro PUMP sHur OFF <br /> AUDIBLE AND VISUAL ALARMS AUDIBLE AND VISUAL ALARMS <br /> 0 15. AUTOMATIC LINE IEAK DETECTOR(3.0 GPHTEST)WITHOUT FLOW 0 15. AUTOMATIC LINE LEAK DETECTOR(3-0 GPH TEST) <br /> SHUT OFF OR RESTRICTION <br /> El 16.ANNUAL 11-TrEGRITY TEST(0-1 GPM (j 16.ANNUAL INTEGRITY TEST(0.1 GPM <br /> [117.DAILY VISUAL CHECK 0 17.DAILY VISUAL CHECK <br /> VIII.DISPENSER CONTAINMENT <br /> DISPENSER CONTAINMENT [11.FLOAT MECHANISM THAT SUMS OFF SHEAR VALVE 0 4.DAILY VISUAL CHECK <br /> DATE INSTALLED 468 E3 2.CONTINUOUS DISPENSER PAN SENSOR+AUDIBLE AND VISUAL ALARMS 0 5.TRENCH LINER/MONITORING <br /> N/A [13.CONTINUOUS DISPENSER PAN SENSOR AUTO SHUT OFF FOR 0 6.NONE 469 <br /> DISPENSER+AUDIBLE AND VISUAL ALARMS <br /> DL OWNER/OP ERATOR SIGNATURE <br /> I oer*that themformstionprovided hevem istmeand acowatetothebest of7myknowledm <br /> ST ATURE BATOR OFOWNER/rDATE 470 <br /> C, 10/16/03 <br /> 14ANM OF OWNER/OPRATOP6") I= OF OWNER/OPERATOR. 472 <br /> Amy .Dy Agent-for Owner <br /> Peand Number(Forlocaluse only) 413 Pea it Approved F. Perad Expiration Date(For local use only) 415 <br />