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01/08/2004 08:23 209468 FIFTH FLOOR PAGE :21
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<br /> UNIFIES PROGRAM CONSOLIDATED FORM
<br /> TANKS
<br /> UNDERGROUND STORAGE TANKS-TANK PAGE 2
<br /> �;'Iy^ 111 to a Writ
<br /> PaLe _
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<br /> ..,, 1. ,,. , ..:VIrPT2�L'KC'.�i7iVSTxtU.C1'2(ON ..••, Il � +.
<br /> ., .. _,,. w G1icek Al)tL4tra )•' ••. ..':;y.;. '.I1...•.-1..-1. :..._.i` ,,,.,:`' s1__
<br /> UNDERGROUND PIPING ABOVEGROUND PIPING
<br /> SYSTEM TYPE 1.PRESSURE ❑2.SUCTION ❑3,GRAVITY 458. ❑1.PRESSURE ®2.SUCTION Q 3.GRAVITY 454.
<br /> CONSTRUCTION/ p,,SINGLE WALL ❑3,LINED TRENCH [199,OTHER 460. ❑1.SINGLE WALL ❑95.UNI(NOWN 51.
<br /> MANUFACTURER
<br /> DOUBLE WALL p95.UNKNOWN p 2.DOUBLE WALL ❑99.OT.iER
<br /> MANUFYTVRER 461, MANUFACTURER
<br /> ❑1,BARE STEEL 6.FRP COMPATIBLE W/100%METHANOL [11.BARE STEEL ❑6.FRP COMPATIBLE W/300%ME'HANCL
<br /> [12.STAINLESS STEEL [17.GALVANIZED STEEL [12.STAINLESS STEEL ❑7.GALVANIZED STEEL
<br /> ❑1 PLASTIC COMPATIBLE WITH CONTENTS ❑95.UNKNOWN ❑3.PLASTIC COMPATIBLE W/CONTENTS ❑8.FLEXIBLE(Hc PE) ❑'99.OTHER.
<br /> 0 4.FIBERGLASS ❑8.FLEXIBLE(HDPE) 0 99.OTHER [14.FIBERGLASS ❑9.CATHODIC PROTECTION
<br /> ❑S.STEEL W/COATING ❑9.CATHODIC PROTECTION 461, ❑5.STEEL W/COATING ❑.95.UNKNOWN -v5.
<br /> 1''1.1`111 1!'V�.C:�IEING'IjE:AIC�IOETEC%xXOlY:�ikillili�i I 1
<br /> 6.G", ,' . 1..:,! ( S4 tIA'Oos'et°,: oTt+iennnitod '"• Ixl"w'II6e'rw�nktedmtL�'bca!• ,Iran'• ;j,_„-,! •_I�j'
<br /> UNDERGROUND PIPING ABOVEGROUND.PIPING
<br /> SINGLE WALL PIPING 466, SINGLE WALL PIPTNG c67
<br /> PRESSURIZED PIPING(Check:all that apply); PRESSURIZED PIPING(Check all that apply):
<br /> ❑1. ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST NITH AUTO PUMP [11. ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TF-';T WITH AUTO PUAIP
<br /> SHUT-OFF FOR LEAKSYSTEM FAILURE,AND SYSTEM DISCONNECTION SHUT OFF FOR LEAK SYSTEM FAILURE,AND SYSTEM 019CONNECTION
<br /> +AUDIBLE AND VISUAL ALARMS. +AUDIBLE AND VISUAL ALARMS,
<br /> ❑2. MONTHLY 0.2 GPH TEST ❑2. MONTHLY 01 OPH TEST
<br /> [13, ANNUAL INTEGRITY TEST(0,1 GPH) ❑3. ANNUAL INTEGRITY TEST(0,I GPH)
<br /> ❑4. DAILY VISUAL CHECK
<br /> CONVENTIONAL SUCTION SYSTEMS CONVENTIONAL SUCTION SYSTEMS(Check all that DPPIY)
<br /> ❑S. DAILY VISUAL MONITORING OF P1JMrMNG SYSTEM+TRIE`NIAL PIPING L]5. DAILY VISUAL MONITORWO OF PIPING AND PUMPING SYSTEM
<br /> INTEGRITY TEST(0.1 GPH)
<br /> SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND KPI NG)1 L36. TRIENNIAL INTEGRITY TEST(0.1 GPH)
<br /> ❑7. SELF MONITORING SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GRCUND PIPING):
<br /> GRAVITY FLOW ❑7. SELF MONITORUNG
<br /> [19. BIENNIAL INTEGRITY TEST(0.1 GPH) GRAVITY FLOW(Check all that apply):
<br /> ❑N. DAILY VISUAL MONITORING
<br /> [39. BIENNIAL INTEGRITY TEST(0.1 GPH)
<br /> SECONDARILY CONTAINED PIPING SECONDARILY CONTAINED PIPING
<br /> PRESSURIZED PIPING(Check all that apply)! PRESSURIZED PIPING(Check all tont apply):
<br /> 10. CONTINUOUS TURBINE SUZAP SENSOR MW AUDIBLE AND VISUAL 10. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISJAL
<br /> ALARMS AND(Check one) ALARMS AND(Check orae)
<br /> ❑a. AUTO PUMP SHUT OFF WHEN A LEAK OCCURS ❑a.AUTO PUMP SHUT OFF WHEN A LEAK OCCURS
<br /> AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM ❑b.AUTO Pump SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM
<br /> DISCONNECTION DISCONNECTION
<br /> ❑c, NO AUTO PUMP SHUT Orr• ❑c. NO AUTO PUMP E14UT OFF
<br /> UJI 1, AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)W[TH FLOW SHUT ®11 AUTOMATIC LEAK DETECTOR
<br /> OFF OR RESTRICTION
<br /> [312, ANNUAL INTEGRITY TEST(0.1 6171,1) ❑12.ANNUAL INTEGRITY TEST(0.1 GPH)
<br /> SUCTIOINJGRAVITY SYSTEM SUCTION/GRAVI'T'Y SYSTEM
<br /> ❑13. CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS ❑13.CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL AL4RMS
<br /> EMERGENCY GENERATORS ONLY(Check all that apply) EMERGENCY GENERATORS ONLY(Check alt that apply)
<br /> [114. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SPILT OFF ❑14.CONTINUOUS SUMP SENSOR WIT1407JT AUTO PUMP SHUT OFF
<br /> AUDMLE AND VISUAL ALARMS AUDIBLE AND VISUAL ALARMS
<br /> ❑15. AUTOMATIC LINE LEAK DETECTOR (3.0 CPR TEST) WTT14OUT FLOW ❑15.AUTOMATIC LINE LEAKDETECTOR(3,0GPHTEST)
<br /> SHUT OFF OR RESTRICTION
<br /> [116. ANNUAL INTEGRITY TEST(0,1 GPH) ❑16,ANNUAL INTEGRITY TEST(0.1 GPH)
<br /> [317. DAILY VISUAL CHECK L317.DAILY VISUAL CHECK
<br /> lain r P
<br /> 11 ......d 11 a re m u' 11 olal ,url 1s
<br /> 1 ()(1 ,..1",', 111f 1.•II .. I�• •k if 1:TTL6.!'YF,PA:i'F9:'W�i4n�1,i2331V11:e.tv6 111 il!11 11„1..1'.11:t, '.I lw!!�•
<br /> DISPENSER CONTAINMENT 463, 1. FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE Q 4. DAILY t'ISUAL COCK 46s�.
<br /> DATE INSTALLED CONTINUOUS DISPENS m PAN SENSOR+AUDIBLE AND VISUAL ALARMS [35. TRFNCF,/LINER IVONITOItLYti
<br /> CONTINUOUS DISPENSER PAN SENSOR' W[TH AUTO SENT OFF fOR ,❑6. NONE
<br /> DISPENSER+AUDIBLE AND VISUAL ALARMS
<br /> PERA;xO ILIu IG
<br /> :., .r. w 1•'1.,(} OW�TEIzlO : :�A'�Cf�', 1 � •111•.1 r.l. I•. _
<br /> I certify that th s'on provided herein' true and ac4uratc to the best of any knowledge.
<br /> SIGNATURE Ok2fN OPERATOR tea® DATE, v ! ' O
<br /> 47D
<br /> --
<br /> NAME Of OtvNER/OPERATOR(Orint).JO,F N^� � _ / TITLE 0 wNEtY! PERATOR! 0 472 1
<br /> uLYT /v tN 1�J7G1L.
<br /> Permit Number(Ag77
<br /> ency use only) 473. Permit Approved By(Agency use only) 474, 1 Permit Expiration Date(Agency two only) 473.
<br /> eeul.wo�w�e®
<br /> UPCF hwfwre-b(1/99)-3/4 9ttp:/hVWw.0nidoQAn Rev.02/16/130
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