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�IFIED PROGRAM CONSOLIDATED FORM TANK: TA0515737 PR 8: PRO523176 UNDERGROUND STORAGE TANKS - TANK PAGE 2 FAC N: FA0015W VL PIPING CONSTRUCTION tlw w i,) Pegs 3 a3 UNDERGROUND PIBING ABOVEGROUND PIPING SYSTEM TYPE ❑ I.PRESSURE ® 2.SUCTION ❑ 3.GRAVITY 458 ❑ 1.PRESSURE ❑ 2.SUCTION ❑ 3.GRAVITY 459 CONSTRUCTION ®1,SINGLE WALL 03.LINED TRENCH ❑ W OTHER 460 ❑ 1,SINGLE WALL ❑ 95.UNKNOWN 462 ❑2.DOUBLE WALL ❑95.UNKNOWN ❑2,DOUBLE WALL ❑ 99,OTHER MANUFACTURER m1 MANUFACTURER 463 ® L BARE STEEL ❑6.FRP COMPATIBLE w/i0 METHANOL ❑ 1,BARE STEEL ❑ 6,FRP COMPATIBLE w/100!6 METHANOL ❑2.STAINLESS STEEL ❑ 7.GALVANIZED STEEL ❑2.STAINLESS STEEL ❑ 7.GALVANIZED STEEL ❑ PLASTIC COMPATIBLE W1 CONTENTS ❑ 95.UNKNOWN ❑PLASTIC COMPATIBLE W/CONTENTS ❑ 95.UNKNOWN ❑4.FIBERGLASS 1:18 FLEXIBLE(HDPE) ❑ 99.OTHER ❑4.FIBERGLASS ❑ 8.FLEXIBLE(HOPE) ❑99,OTHER ❑5.STEEL W/COATING ❑9.CATHODIC PROTECTION 46a ❑5.STEEL W/COATING ❑ 9.CATHODIC PROTECTION VII.PIPING LEAK DETECTION(CheN a w W11)(A ammiPtbuoTih mmuLtslptoHom atoll be ubmttred b ah lural ) UNDERGROUND PIPING ABOVEGROUND PIPING SINGLE WALL PIPING 466 SINGLE WALL PIPING 467 PRESSURIZED PH-ING(Check all that apply)-. PRESSURIZED PIPING(Check all that appy): ❑ 1.ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP SHUT OFF ❑ I.ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP SHUT OFF FOR LEAK,SYSTEM FAILURE,AND SYSTEM DISCONNECTION-AUDIBLE AND FOR LEAR,SYSTEM FAILURE,AND SYSTEM DISCONNECTION+AUDIBLE AND VISUAL ALARMS' VISUAL ALARMS. ❑2.MONTHLY 0.2 GPH TEST ❑ 3.ANNUAL INTEGRITY TEST(0,1 GPH) ❑ Z MONTHLY 0.2 GPH TEST ❑ 3.ANNUAL INTEGRITY TEST(0.1 GPH) ❑4,DAILY VISUAL CHECK CONVENTIONAL SUCTION SYSTEMS CONVENTIONAL SUCTION SYSTEMS(Check all that apply) ❑ 5.DAILY VISUAL MONITORING OF PUMPING SYSTEM+TRIENNIEAL PIPING ❑ 5.DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM INTEGRITY TEST 10.1 GPH) ❑ 6.TRIENNIAL INTEGRITY TEST(0.1 GPH) SAFE SUCTION SYSTEMS(NO VALUES IN BELOW GROUNDPBING): El 7.SELF MONITORING SAFE SUCTION SYSTEMS(NO VALUES IN BELOW CROUNDPIPING): GRAVITY FLOW C] 7.SELF MONITORING ❑9.BIENNIAL INTEGRITY TEST(0.1)GPH GRAVITY FLOW(Chock all that appy): ❑ 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 WITH AUDIBLE AND VISUAL 10.CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL ALARMS AND(Check oee) ALARMS AND(Ch k mc) ❑a AUTO PUMP SHUT OFF WHEN A LEAK OCCURS ❑ a.AUTO PUMP SHUT OFF WHEN A LEAK OCCURS ❑b,AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM ❑b.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(3.0 GPH TEST)WITH FLAW SHUT OFF OR ❑ 11 AUTOMATIC LEAK DETECTOR RESTRICTION ❑ 12.ANNUAL INTEGRITY TEST(0.1 GPH) ❑ 12.ANNUAL INTEGRITY TEST(0,1 GPH) SUCTION/GRAVITY SYSTEM SUCTION/GRAVITY SYSTEM ❑ 13,CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS ❑ 13.CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS EMERGENCY GENERATORS ONLY(C tll thn wi,) EMERGENCY GENERATORS ONLY(Chi W"apply) ❑ 14.CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF• ❑ 14.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)WITH FLOW ❑ I5.AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)WITHOUT FLOW SHUT OFF OR RESTRICTION SHUT OFF OR RESTRICTION ❑ 16.ANNUAL INTEGRITY TEST(0.1 GPH) ❑ 16.ANNUAL INTEGRITY TEST(0.1 GPH) ❑ 17.DAILY VISUAL CHECK ❑ 17,DAILY VISUAL CHECK VIIL DISPENSER CONTAP4MNT DISPENSER CONTAINMENT ❑ 1,FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE ❑4.DAILY VISUAL CHECK DATE INSTALLED �p 2 CONTINUOUS DISPENSER PAN SENSOR AND VISUAL ALARMS ❑ ❑ S.TRENCH LINER/MONITORING ❑3.CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR ❑6,NONE DISPENSER+AUDIBLE AND VISUAL ALARMS 469 DL OWNER/OPERATOR SIGNATURE 1 ani(y Wu me bT9amxcm povkdhv®h trot and emaalem Em bntMmy Bm9wledge. SIGNATURE OF OWNER/OPERATOR DATE 420 NAME OF OWNER/OPERATOR(print) TITLE OF OWNER/OPERATOR WILLIAM LITTLE d71 AGENT 472 Pmmh Nw (F.hW meoab') 473 Pvmit Apinwed(Fm but ueaNy) 474 Permit Fivh D (Fmk mealy) 475 UPCF(12/99 revised)