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UNIFIED PROGRAM CONSOLIDATED FORM TANKS UNDERGROUND STORAGE TANKS-TANK PAGE 2 Pageof VI.PIPING CONSTRUCTION CMck a1 that. 1) UNDERGROUND PIPING ABOVEGROUND PIPING SYSTENI TYPE .PRESSURE 0 2.SUCTION [13.GRAVITY 458, O 1.PRESSURE 0 2.SUCTION 0 3.GRAVITY 459. CONSTRUCTION/ 1.SINGLE WALL [13.LINED TRENCH 0 99.OTHER 460. 0 1.SINGLE WALL 0 95.UNKNOWN 462. MANUFACTURER .d DOUBLE WALL ❑95.UNKNOWN ❑2.DOUBLE WALL ❑99.OTHER MANUFACTURER A P T 461. MANUFACTURER 463. 0 1.BARE STEEL 0 6.FRP COMPATIBLE W/100%METHANOL 0 1.BARE STEEL 0 6.FRP COMPATIBLE W/100%METHANOL 0 2.STAINLESS STEEL 0 7.GALVANIZED STEEL 0 2.STAINLESS STEEL [17.GALVANIZED STEEL 0 3.PLASTIC COMPATIBLE WITH CONTENTS 0 95.UNKNOWN 0 3.PLASTIC COMPATIBLE W/CONTENTS 0 8.FLEXIBLE(HDPE) 0 99.OTHER 0 4.FIBERGLASS IX.FLEXIBLE(HDPE) 0 99.OTHER ❑4.FIBERGLASS 0 9.CATHODIC PROTECTION 0 S.STEEL W/COATING 0 9.CATHODIC PROTECTION 464. 0 5.STEEL W/COATING 0 93.UNKNOWN 465. VII.PIPING LEAK DETECTION tebeek.0 mu 1)(AeeKeirio..f be manh9d. m. t Mll hembmibo nalmthe la .) UNDERGROUND PIPING am ABOVEGROUND PIPING SINGLE WALL PIPING 466. SINGLE WALL PIPING 467. PRESSURIZED PIPING(Check all that apply): PRESSURIZED PIPING(Check all that apply): 01. ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP 01. ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP SHUT-OFF FOR LEAK SYSTEM FAILURE,AND SYSTEM DISCONNECTION SHUT OFF FOR LEAK SYSTEM FAILURE,AND SYSTEM DISCONNECTION +AUDIBLE AND VISUAL ALARMS. +AUDIBLE AND VISUAL ALARMS. [12. MONTHLY 0.2 GPH TEST 02. MONTHLY 0.2 GPH TEST 03. ANNUAL INTEGRITY TEST(0.1 GPH) 03. ANNUAL INTEGRITY TEST(0.1 GPH) 04. DAILY VISUAL CHECK CONVENTIONAL SUCTION SYSTEMS CONVENTIONAL SUCTION SYSTE51S(Cheek all that apply) 05. DAILY VISUAL MONITORING OF PUMPING SYSTEM+TRIENNIAL PIPING 05. DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM INTEGRITY TEST(0.1 GPH) SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): 06. TRIENNIAL INTEGRITY TEST(0.1 GPH) 07. SELF MONITORING SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): GRAVITYFLOW 07. SELF MONITORING 09. BIENNIAL INTEGRITY TEST(0.1 OPH) GRAVITY FLOW(Check all that apply): 08. DAILY VISUAL MONITORING 09. BIENNIAL INTEGRITY TEST(0.1 GPH) SECONDARILY CONTAINED PIPING SECONDARILY CONTAINED PIPING PRESSURIZED PIPING(Check all that apply): PRESSURIZED PIPING(Check all that apply): 10. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL 10. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL ALARMS AND(Check one) ALARMS AND(Check one) 0 a. AUTO PUMP SHUTOFF WHEN A LEAK OCCURS 0 a. AUTO PUMP SHUT OFF WHEN A LEAK OCCURS lRb.AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM 0 b.AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM DISCONNECTION DISCONNECTION Oc. NOAUTOPUMPSHUTOFF Oc. NOAUTOPUMPSHUTOFF {� W 11. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)WITH FLOW SHUT 0 11 AUTOMATIC LEAK DETECTOR OFF OR RESTRICTION 0 12. ANNUAL INTEGRITY TEST(0.1 GPH) 0 12.ANNUAL INTEGRITY TEST(0.1 GPH) SUCTION/GRAVITY SYSTEM SUCTION/GRAVITY SYSTEM 013. CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS 013. CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS EMERGENCY GENERATORS ONLY(Check all that apply) EMERGENCY GENERATORS ONLY(Check all that apply) 014. CONTINUOUS SUMP SENSOR WITHOl7f AUTO PUMP SHUT OFF 014.CONTINUOUS SUMP SENSOR WITHOIIf AUTOPUMPSHUTOFF AUDIBLE AND VISUAL ALARMS AUDIBLE AND VISUAL ALARMS 015. AUTOMATIC LINE LEAK DETECTOR (3.0 GPH TEST) WITHOUT FLOW 015.AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST) SHUT OFF OR RESTRICTION 016. ANNUAL INTEGRITY TEST(0.1 GPH) O 16.ANNUAL INTEGRITY TEST(0.1 GPH) 017. DAILY VISUAL CHECK 017. DAILY VISUAL CHECK VIII.DISPENSER CONTAINMENT DISPENSER CONTAINMENT 468. �❑/1. FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE 04. DAILY VISUAL CHECK 469. DATE INSTALLED p� CONTINUOUS DISPENSER PAN SENSOR.AUDIBLE AND VISUAL ALARMS [35. TRENCH/LINER MONITORING Z b C) 0 3. CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR 0 6. NONE DISPENSER+AUDIBLE AND VISUAL ALARMS IX.OWNER/OPERATOR SIGNATURE I certify that the information provided herein is true and accurate to the best of my knowledge. TU EOF E OPE 70R DATE: g'/ , ✓J2- Oro' ar Ct v>tic'oca 472. NAME OF OWNER/OPERATOR(print): TITLE OF OWNER/OPERATOR: Permit Number(Agency use only) 473. 1 Permit Approved By(Agency use only) 474. 1 Permit Expiration Date(Agency we only) 475. UPCF hwfwrc-b(1/99)-3/4 hap://www.unidoes.org Rev.02/16/00