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UNIFIED PROGRAM CONSOLIDATED FORM TANKS UNDERGROUND STORAGE TANKS- TANK PAGE 2 VL PIPING CONSTRUCTION(Check all,thatapply) Pae of UNDERGROUND PIPING ABOVEGROUND PIPING SYSTEM TYPE L PRESSURE ❑2.SUCTION ❑3.GRAVITY 45a. ❑I.PRESSURE CONSTRUCTION/ ❑2.SUCTION [13.GRAVITY 459, MANUFACTURER ❑1.SINGLE WALL ❑3.LINED TRENCH ❑99.OTHER 460. ❑1.SINGLE WALL 2.DOUBLE WALL ❑95.UNKNOWN 462. ❑95.UNKNOWN ❑2.DOUBLE WALL ❑99.OTHER MANUFACTURER MANUFACTURER ❑1.BARE STEEL ❑6.FRP COMPATIBLE W/100%METHANOL 463. ❑1.BARE STEEL ❑6.FRP COMPATIBLE W/100%METHANOL ❑2.STAINLESS STEEL ❑7.GALVANIZED STEEL ❑2.STAINLESS STEEL ❑3.PLASTIC COMPATIBLE WITH CONTENTS ❑7.GALVANIZED STEEL ❑95.UNKNOWN ❑3.PLASTIC COMPATIBLE W/CONTENTS ❑8.FLEXIBLE(HDPE) ❑99.OTHER El 4.FIBERGLASS ❑8.FLEXIBLE(HDPE) ❑99.OTHER ❑4.FIBERGLASS ❑5.STEEL W/COATING ❑9.CATHODIC PROTECTION 464. ❑9•CATHODIC PROTECTION ❑5.STEEL W/COATING ❑95.UNKNOWN VII.PIPING LEAK DETECTION(Check all that A descri tionof the momtor ol?ra<ashall be sub n ted'to the local 465. UNDERGROUND PIPING .) SINGLE WALL PIPING ABOVEGROUND PIPING 466. SINGLE WALL PIPING PRESSURIZED PIPING(Check all that apply): 467. ❑ PRESSURIZED PIPING(Check all that apply):1. ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP El 1. ELECTRONIC LINE LEAK DETECTOR 3.0 GPM TEST WITH AUTO PUMP SHUT-OFF FOR LEAK,SYSTEM FAILURE,AND SYSTEM DISCONNECTION SHUT OFF FOR LE +AUDIBLE AND VISUAL ALARMS. AK SYSTEM FAILURE,AND SYSTEM DISCONNECTION +AUDIBLE AND VISUAL ALARMS. ❑2. MONTHLY 0.2 GPM TEST [12. MONTHLY 0.2 GPM TEST ❑3. ANNUAL INTEGRITY TEST(0.1 GPM) ❑3. ANNUAL INTEGRITY TEST(0.1 GPH) [:14. DAILY VISUAL CHECK CONVENTIONAL SUCTION SYSTEMS ❑ CONVENTIONAL SUCTION SYSTEMS(Check all that apply) 5. DAILY VISUAL MONITORING OF PUMPING SYSTEM+TRIENNIAL PIPING INTEGRITY TEST(0.1 GPM) ❑5. DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): ❑6. TRIENNIAL INTEGRITY TEST(0.1 GPM) ❑ GRAVITY FLOW SELF MONITORING GRASAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): [3 7. SELF MONITORING [19. BIENNIAL INTEGRITY TEST(0.1 GPM) GRAVITY FLOW(Check all that apply): PP Y): ❑8. DAILY VISUAL MONITORING [39. BIENNIAL INTEGRITY TEST(0.1 GPM) 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) Aa.AUTO PUMP SHUT OFF WHEN A LEAK OCCURS ❑a. AUTO PUMP SHUT OFF WHEN A LEAK OCCURS Xb.AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM ❑b.AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM DISCONNECTION DISCONNECTION [1c. NO AUTO PUMP SHUT OFF ❑c. NO AUTO PUMP SHUTOFF ❑11. AUTOMATIC LINE LEAK DETECTOR(3.0 GPM TEST)WITH FLOW SHUT OFF OR RESTRICTION ❑ I I.AUTOMATIC LEAK DETECTOR ❑12. ANNUAL INTEGRITY TEST(0.1 GPM) ❑ 12. ANNUAL INTEGRITY TEST(0.1 GPM) SUCTION/GRAVITY SYSTEM SUCTION/GRAVITY SYSTEM ❑13. CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS [113.CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS EMERGENCY GENERATORS ONLY(Check all that apply) EMERGENCY GENERATORS ONLY(Check all that a 1 El 14. CONTINUOUS-SUMP SENSOR W TI HOUT AUTO PUMP SHUT OFF ❑l4.CONTINUOUS SUMP SENSOR WIO T Y) AUDIBLE AND VISUAL ALARMS AUTO PUMP SHUT OFF ❑15. AUTOMATIC LINE LEAK DETECTOR (3.0 GPM TEST) WITHOUT FLOW AUDIBLE AND VISUAL ALARMS SHUT OFF OR RESTRICTION ❑15.AUTOMATIC LINE LEAK DETECTOR(3.0 GPM TEST) ❑16. ANNUAL INTEGRITY TEST(0.I GPM) [116. ANNUAL INTEGRITY TEST(0.1 GPM) ❑ 17. DAILY VISUAL CHECK ❑17. DAILY VISUAL CHECK VIII.DISPENSER CONTAINMENT DISPENSER CONTAINMENT 468. 1. FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE DATE INSTALLED ❑2. CONTINUOUS DISPENSER PAN SENSOR+AUDIBLE AND VISUAL ALARMS ❑4. DAILY VISUAL CHECK 469. [033. CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR 05. 5 TRENCH/LINER MONITORING DISPENSER+AUDIBLE AND VISUAL ALARMS ❑6. NONE IX.OWNER/OPERATOR SIGNATURE I certify that the information provid herein is true and accurate to the best of my knowledge. SIGNATURE OF OWNER/OPERATOR DATE: / 470. NAME OFOWNER/OPERATOR(print):n �� - TITLE OF OWNER/OPERATOR:1 , J 472. Permit Number(Agency use only) " 473. Permit Approved` By(Agency use onl Y) 474. Permit Expiration Date(Agency use only) 475. UPCF hwfwm-b(1/99)-3/4 httP://Www.unidocs.otg Rev.02/16/00