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UNIFIED PROGRAM CONSOLIDATED FORM TANKS UNDERGROUND STORAGE TANKS -TANK PAGE 2 1 0 VI.PIPING CONSTRUCTION(Checkalfhatapply) ABOVEGROUND PIPING UNDERGROUND PIPING SYSTEM TYPE 1 PRESSURE C32 SUCTION ❑ ] GRAVITY ❑ 1 PRESSURE C1 2. SUCTION C1 ] GRAVITY ❑ 1 NGLE WALL ❑ ] LINED TRENCH ❑99 OTHER ❑ 1 SINGLE WALL ❑95 UNKNOWN CONSTRUCTION/ ' MANUFACTURER 2 DOUBLE WALL ❑CS U11�Nn/WW ❑ 2 DOUBLE WALL ❑99 OTHER MANUFACTURER Eh v;roo y�O % O MANUFACTURER ❑ 1 BARE STEEL ❑ b FRP COMPATIBLE W/100%METHANOL ❑ 1 BARE STEEL ❑ e. FRP COMPATIBLE W/100°. METHANOL MATERIALS AND ❑ 2. STAINLESS STEEL ❑ 7. GALVANIZED STEEL ❑ 2 STAINLESS STEEL ❑ 7. GALVANIZED STEEL \ PROTECTION ❑ ] PLASTIC COMPATIBLE WITH NTENTS ❑95 UNKNOWN ❑ 1 PLASTIC COMPATIBLE WITH CONTENTS ❑ E FLEXIBLE(HDPE) 99 OTHER CORROSION • ❑ 4 FIBERGLASS E FLEXIBLE(HOPE) , 99 OTHER. Q FIBERGLASS C3 0 CATHODIC PROTECTION ❑ ❑ 5 STEEL W/COATING ❑ 9 CATHODIC PROTECTION ❑ 5 STEEL W/COATING ❑95 UNKNOWN VII.PIPING LEAK DETECTIQ)4(Chock all that apply) ABOVEGROUND PIPING UNDERGROUND PIPING SINGLE WALL PIPING SINGLE WALL PIPING PRESSURIZED PIPING(Check all that apply). PRESSURIZED PIPING(Check ad that ap,oly) C3 I ELECTRONIC LINE LEAK DETECTOR].0 GPM TEST WITH AUTO PUMP SMUT Off FOR C3 t. ELECTRONIC LINE LEAK DETECTOR]0 GPM TEST WITH AUTO PUMP SMUT OFF FOR LEAK, LEAK,SYSTEM FAILURE,AND SYSTEM DISCONNECTION•AUDIBLE AND VISUAL SYSTEM FAILURE.AND SYSTEM DISCONNECTION•AUDIBLE AND VISUAL ALARMS ALARMS ❑ 2 MONTHLY 0.2 GPM TEST ❑ 2. MONTHLY G 2 GPM TEST ❑ ] ANNUAL INTEGRITY TEST(0.1 GPM) ❑ ] ANNUAL INTEGRITY TEST(0 1 GPM) ❑ 4 DAILY VISUAL CHECK CONVENTIONAL SUCTION SYSTEMS(Chock all that apply? CONVENTIONAL SUCTION SYSTEMS ❑ S DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM C15 DAILY VISUAL MONITORING OF PUMPING SYSTEM•TRIENNIAL PIPING INTEGRITY C16 TRIENNIAL INTEGRITY TEST(0.1 GRH) TEST(0 1 GPM) SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING) SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING) ❑ 7 SELF MONITORING ❑ 7 SELF MONITORING GRAVITY FLOW GRAVITY FLOW(Chock aI that apply) ❑ 9 BIENNIAL INTEGRITY TEST(0 1 GPM) ❑ E DAILY VISUAL MONITORING ❑ 9 BIENNIAL INTEGRITY TEST(O 1 GPM) SECONDARILY CONTAINED PIPING SECONDARILY CONTAINED PIPING PRESSURIZED PIPING(Chock ad that apply): PRESSURIZED PIPING(Chack all that apply): 10 CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL ALARMS AND 10 CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL ALARMS AND(chock one) (LCCn50'bna) ❑ a AUTO PUMP SHUT OFF WHEN A LEAK OCCURS LYS AUTO PUMP SHUT OFF WHEN A LEAK OCCURS ❑ b AUTO PUMP SHUT OFF FOR LEAKS.SYSTEM FAILURE AND SYSTEM ❑ 17 AUTO PUMP SHUT OFF FOR LEAKS.SYSTEM FAILURE AND SYSTEM DISCONNECTION DISCONNECTION ❑ c. NO AUTO PUMP SHUT OFF ❑ C. NO AUTO PUMP SHUT OFF 11 AUTOMATIC LINE LEAK DETECTOR(]0 GPM TEST)WITH FLOW SHUT OFF OR ❑ 11 AUTOMATIC LEAK DETECTOR RESTRICTION ❑ 12 ANNUAL INTEGRITY TEST(0 1 GPM) ❑ 12 ANNUAL INTEGRITY TEST(0 1 GPM) SUCTIONIGRAVITY SYSTEM SUCT'OtUGRAVITY SYSTEM. ❑ 11 CONTINUOUS SUMP SENSOR•AUDIBLE AND VISUAL ALARMS ❑ 13 CONTINUOUS SUMP SENSOR•AUDIBLE AND VISUAL ALARMS EMERGENCY GENERATORS ONLY(Check as that apply) EMERGENCY GENERATORS ONLY(Chock atl that appy ❑ 14 CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF•AUDIBLE AND ❑ 14 CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF•AUDIBLE AND VISUAL VISUAL ALARMS ALARMS ❑ 15 AUTOMATIC LINE LEAK DETECTOR(]0 GPM TEST)WTHOUT FLOW SHUT OFF OR ❑ 15 AUTOMATIC LINE LEAK DETECTOR(1.0 GPM TEST) RESTRICTION C319 ANNUAL INTEGRITY TEST(0 1 GRH) ❑ 16 ANNUAL INTEGRITY TEST(0.1 GPM) ❑ 17. DAILY VISUAL CHECK C317 DAILY VISUAL CHECK VIIL DISPENSER CONTAINMENT DISPENSER CONTAINMENT ❑). FLOAT MECHANISM THAT SHUTS OFF SMEAR VALVE C:] 4. DAILY VISUAL CHECK 1� DATE INSTALLED 2. CONTINUOUS DISPENSER PAN SENSOR.AUDIBLE AND VISUAL ALARMS [1 5. TRENCH LINER I MONITORING ❑ 1. CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR DISPENSER•AUDIBLE AND VISUAL ALARMS ❑ E. NONE IX.OWNERIOPERATOR SIGNATURE ------------ I unify that the INormallon provided herevl is We and acc=�T.LE MY �L SIGNATURE F C ER/OPE TOR � "\4DATE NAM OF OWER.OPERATORlPnnfl�QIV ` r RA h V. ITJVt ? Permit Expiration Date(For local use ONY) Pump Number(For local use only) Penn-Approved(For local use only) Formerly SVvRCB Form B CUPAFORM(4199)