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UNIFIED PROGRAM CONSOLIDATED FORM TANKS IF UNDERGROUND STORAGE TANKS —TANK PAGE 2 Pap /O VI.PIPING CONSTRUCTION(Check as that appy) UNDERGROUND PIPING ABOVEGROUND PIPING SYSTEM TYPE 1 PRESSURE ❑ 2 SUCTION ❑ ] GRAVITY ❑ 1 PRESSURE ❑ 2. SUCTION ❑ ] GRAVITY CONSTRUCTION/ G WALL ❑ 3 LINED TRENCH [:199 OTHER ❑ i SINGLE WALL ❑95 UNKNOWN MANUFACTURER 2 DOUBLE WALL ^SJJNKNO}MN C3 2 DOUBLE WALL 99 OTHER MANUFACTURER ,+ 6"V� *a In G#.o-pI-2,c MANUFACTURER ❑ 1 BARE STEEL C1 FRP COMPATIBLE W/100%METHANOL ❑ 1 BARE STEEL ❑ 6. FRP COMPATIBLE At 100%METHANOL MATERIALS AND ❑ 2. STAINLESS STEEL ❑ 7. GALVANIZED STEEL ❑ 2. STAINLESS STEEL ❑ 7. GALVANIZED STEEL CORROSION PROTECTION ❑ 3 PLASTIC COMPATIBLE WITH CONTENTS ❑95 UNKNOWN ❑ 3 PLASTIC COMPATIBLE WITH CONTENTS C1 E FLEXIBLE(HDPE) 99 OTHER [:14 FIBERGLASS LSE FLEXIBLE(HOPE) ❑99. OTHER. - ❑ 4 FIBERGhASS ❑ 9 CATHODIC PROTECTION ❑ 5 STEEL W/COATING ❑ 9. CATHODIC PROTECTION ❑ 5 STEEL W!COATING ❑95 UNKNOWN VII.PIPING LEAK DETECTION(Check an that appy) UNDERGROUND PIPING ABOVEGROUND PIPING SINGLE WALL PIPING SINGLE WALL PIPING PRESSURIZED PIPING(Check as that appy). PRESSURIZED PIPING(Check all that ap,oy) ❑ 1 ELECTRONIC LINE LEAK DETECTOR 3 0 GPM TEST WITH AUTO PUMP SHUT OFF FOR ❑ 1. ELECTRONIC LINE LEAK DETECTOR 3 0 GPM TEST WITH AUTO PUMP SHUT OFF FOR LEAK, LEAK,SYSTEM FAILURE.AND SYSTEM DISCONNECTION•AUOIBLE AND VISUAL SYSTEM FAILURE.AND SYSTEM DISCONNECTION.AUDIBLE AND VISUAL ALARMS ALARIAS ❑ 2 MONTHLY 0 2 GPH TEST ❑ 2 MONTHLY 0 2 GPH TEST ❑ 3 ANNUAL INTEGRITY TEST(0.1 GPH) ❑ 3 ANNUAL INTEGRITY TEST(0 1 GPM) C1.4 DAILY VISUAL CHECK CONVENTIONAL SUCTION SYSTEMS(Check ad Nat appy), CONVENTIONAL SUCTION SYSTEMS ❑ S DAILY VISUAL A10NITORINC OF PUMPING SYSTEM.TRIENNIAL PIPING INTEGRITY ❑ 5 DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM TEST(0 1 GPH) ❑ E TRIENNIAL INTEGRITY TEST(0.1 GPH)' SAFE SUCTION SYSTEMS(NO VALVES W BELOW GROUND PIPING) SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING)' ❑ 7 SELF MONITORING ❑ 7 SELF MONITORING GRAVITY FLOW GRAVITY FLOW(Check as that apply) ❑ 9 BIENNIAL INTEGRITY TEST(0 1 GPH) ❑ E DAILY VISUAL MONITORING ❑ 9 BIENNIAL INTEGRITY TEST(O t GPH) SECONDARILY CONTAINED PIPING SECONDARILY CONTAINED PIPING PRESSURIZED PIPING(Check aM that appy): PRESSURIZED PIPING(Check 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(Check one) Cn one) AUTO PUMP SHUT OFF WHEN A LEAK OCCURS C1 . AUTO PUMP SHUT OFF WHEN A LEAK OCCURS C3 AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM C1 AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE ANO SYSTEM DISCONNECTION DISCONNECTION ❑ c. NO AUTO PUMP SHUT OFF C1 c. NO AUTO PUMP SMUT OFF 0 1 t 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 GPH) SUCTION/G RAVI TY SYSTEM SUCTION/GRAVITY SYSTEM ❑ 13 CONTINUOUS SUMP SENSOR•AUDIBLE AND VISUAL ALARMS ❑ 13 CONTINUOUS SUMP SENSOR-AUDIBLE AND VISUAL ALARMS EMERGENCY GENERATORS ONLY(Check as that appy) EMERGENCY GENERATORS ONLY(Check ad that app/» ❑ 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(3 0 GPH TEST)W'THOUT FLOW SHUT OFF OR ❑ 15 AUTOMATIC LINE LEAK DETECTOR(3 0 GPM TEST) RESTRICTION ❑ tE. ANNUAL INTEGRITY TEST(0 1 GPH) ❑ 16 ANNUAL INTEGRITY TEST(0.t GPH) C317. DAILY VISUAL CHECK ❑ 17 DAILY VISUAL CHECK VIIL DISPENSER CONTAINMENT DISPENSER CONTAINMENT ❑ 1 FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE ❑ 4. DAILY VISUAL CMECK DATE INSTALLED 2. CONTINUOUS DISPENSER PAN SENSOR rAUDIBLE AND VISUAL ALARMS ❑ 5. TRENCH LINER/MONITORING ❑ 3 CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR DISPENSER•AUDIBLE AND VISUAL ALARMS ❑ E. NONE IX.OWNER/OPERATOR SIGNATURE I comfy mal the Intotmatan provwod herein is Wa and acutrato to tM OSA of my knowledge SIGNATURE OF OWNER/OPERATOR fog WL.AJ `7 �t i5 1 W ` DATE NA M€OF/ 1 OWN-` LJ ER.OP/�EBATOR!nnt) T�ITtLE OF OWNER/OPERATOR A Ct-L..a . �ct L/:VJ+.�w•d� �A1t /'T `VS Permit Numoer(for local uae only) -F-Penna Approved(Falocal use ony) Pem+lt EApwallon .to(Fa local uae only) Formerly SWRCS Farm B CUPAFORM(4199)