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UNIFIED PROGRAM CONSOLIDATED FORM TANKS UNDERGROUND STORAGE TANKS-TANK PAGE 2 Page of VI.PIPING CONSTRUCTION Cookmlthu 1) UNDERGROUND PIPING ABOVEGROUND PIPING SYSTEM TYPE .PRESSURE ❑2.SUCTION ❑3.GRAVITY 458. ❑1.PRESSURE ❑2.SUCTION [13.GRAVITY 459. CONSTRUCTION/ L SINGI-E WALL ❑3.LINED TRENCH [199.OTHER 460. ❑1.SINGLE WALL [195.UMU40WN 462. MANUFACTURER �.DOUBLE WALL ❑95.UNKNOWN ❑2.DOUBLE WALL ❑99.OTHER MANUFACTURER A Q 461. MANUFACTURER 40. ❑1.BARE STEEL [16.FEP COMPATIBLE W/100%METHANOL ❑I.BARE STEEL [16.FRP COMPATIBLE W/100%METHANOL ❑2.STAINLESS STEEL [17.GALVANIZED STEEL ❑2.STAINLESS STEEL ❑7.GALVANIZED STEEL [13.PLASTIC COMPATIBLE WITH CONTENTS ❑95.UNKNOWN ❑3.PLASTIC COMPATIBLE W/CONTENTS ❑8.FLEXIBLE(HDPE) ❑99.OTHER 4.FIBERGLASS I%.FLEXIBLE(HDPE) [199.OTHER [14.FIBERGLASS ❑9.CATHODIC PROTECTION ❑5.STEEL W/COATING ❑9.CATHODIC PROTECTION 464. [15.STEEL W/COATING ❑95.UNKNOWN 465. VII.PIPING LEAK DETECTION(check.n mu )Uawcnnon onbe monhoan Rroscon shall te men,atm to the local enc.) UNDERGROUND PIING ABOVEGROUND PIPING SINGLE WALL PIPING 466. SINGLE WALL PIPING 4B1, PRESSURIZED PIPING(Check all that apply): PRESSURIZED PIPING(Check all that apply): ❑1. ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP [11. 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. ❑2. MONTHLY 0.2 GPH TEST ❑2. MONTHLY 0.2 GPH TEST ❑3, ANNUAL INTEGRITY TEST(0.1 GPH) [13. ANNUAL INTEGRITY TEST(0.1 GPH) [34. DAILY VISUAL CHECK CONVENTIONAL SUCTION SYSTEMS CONVENTIONAL SUCTION SYSTEMS(Check all that apply) ❑S. DAILY VISUAL MONITORING OF PUMPING SYSTEM+TRIENNIAL PIPING []5. DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM INTEGRITY TEST(0.1 GPH) SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): [36. TRIENNIAL INTEGRITY TEST(0.1 GPH) ❑7. SELF MONITORING SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIING): GRAVITY FLOW ❑7. SELF MONITORING 09. BIENNIAL INTEGRITY TEST(0.1 GPH) GRAVITY FLOW(Check ail that apply): ❑8. DAILY VISUAL MONITORING []9. 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 WIT AUDIBLE AND VISUAL 10. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL ALARMS AND(Check one) ALARMS AND(Check one) ❑a. AUTO PUMP SHUT OFF WHEN A LEAK OCCURS ❑a. AUTO PUMP SHUT OFF WHEN A LEAK OCCURS lgb.AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM ❑b.AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM DISCONNECTION DISCONNECTION Oc. NO AUTO PUMP SHUT OFF [Ic. NO AUTO PUMP SHUTOFF V 11. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)WITH FLOW SHUT 11 AUTOMATIC LEAK DETECTOR OFF OR RESTRICTION [112. ANNUAL INTEGRITY TEST(0.1 GPH) [112.ANNUAL INTEGRITY TEST(0.1 GPH) SUCTION/GRAVITY SYSTEM SUCTION/GRAVITY SYSTEM ❑U. CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS 013.CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS EMERGENCY GENERATORS ONLY(Check ail that apply) EMERGENCY GENERATORS ONLY(Check all that apply) C]14. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF [114.CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF AUDIBLE AND VISUAL ALARMS AUDIBLE AND VISUAL ALARMS ❑15. AUTOMATIC LINE LEAK DETECTOR (3.0 GPH TEST) WITHOUT FLOW [115.AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST) SHUT OFF OR RESTRICTION ❑16. ANNUAL INTEGRITY TEST(0.1 GPH) [116.ANNUAL INTEGRITY TEST(0.1 GPH) [117. DAILY VISUAL CHECK ❑17.DAILY VISUAL CHECK VIII.DISPENSER CONTAINMENT DISPENSER CONTAINMENT 468. ��❑/JB11. FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE ❑4. DAILY VISUAL CHECK 469 ,P . DATEINSTALLED CONTINUOUS DISPENSER PAN SENSOR AUDIBLE AND VISUAL ALARMS ❑5. TRENCH/LINERMONITORING Z O ❑3. CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR E3 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. EOFOPE TOR DATE. S/ -2- / ✓JZ 470 rru'oC4' O 472. NAME OF OWNER/OPERATOR(print): TITLE OF OWNER/OPERATOR: Permit Number(Agency use only) 473. 1 Permit Approved By(Agency rue only) 474. Pemut Expitstion Date(Agency use only) 475. UPCF hwfwrc-b(1/99)-3/4 http://www.unidocs.org Rev.02/16/00