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UNIFIED PROGRAM CONSOLIDATED FORM TANKS UNDERGROUND STORAGE TANKS- TANK PAGE 2 Pae_of VL PIPING CONSTRUCTION Caeck a0taat - UNDERGROUND PIPING ABOVEGROUND PIPING SYSTEM TYPE ❑ 1.PRESSURE 2.SUCTION .GRAVITY 458. ❑1.PRESSURE [12.SUCTION ❑3.GRAVITY 459. CONSTRUCTION/ MANUFACTURER 1.SINGLE WALL ❑7.LINED TRENCH ❑99.OTHER I60. 131.SINGLE WALL [195.UNKKNOWN 462 ❑2.DOUBLE WALL ❑95.UNKNOWN ❑2.DOUBLE WALL ❑99.OTHER MANUFACTURER till. MANUFACTURER 463. 1.BARE STEEL [16.FRP COMPATIBLE W/100%METHANOL 1.BARE STEEL ❑b.FRP COMPATIBLE W/1OOX METHANOL 0 2.STAINLESS STEEL ❑7.GALVANIZED STEEL ❑2.STAINLESS STEEL ❑7.GALVANIZED STEEL ❑3.PLASTIC COMPATIBLE WITH CONTENTS ❑95.UNKNOWN [13.PLASTIC COMPATIBLE W/CONTENTS ❑8.FLEXIBLE(HOPE) ❑99.OTHER ❑4.FIBERGLASS ❑S.FLEXIBLE(HDPE) 0 99.OTHER ❑4.FIBERGLASS ❑9.CATHODIC PROTECTION ❑5.STEEL W/COATING ❑9.CATHODIC PROTECTION 464. ❑5.STEEL W/COATING [195.UNK NOWN 465. VET.PIPING LEAK DETECTION(CEckpllftM I Ai "aorthama afi61T6e iutwhux blh'ekm:agmcy,):. UNDERGROUND PIPING ABOVEGROUND PIPING SINGLE WALL PIPING 466. SINGLE WALL PIPING 467. PRESSURIZED PIPING(Check all that apply): PRESSURIZED PIPING(Check all that apply): ❑1. ELECTRONIC LIKE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP D I. 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 [32. MONTHLY 0.2 OPH TEST [13. ANNUAL INTEGRITY TEST(0.1 GPM,^- ❑3. ANNUAL INTEGRITY TEST(o.l GPH) Ulb ❑4. 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 OPH) 05. DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): [16. TRIENNIAL INTEGRITY TEST(0.1 GPH) ❑7. SELF MONITORING SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): GRAVITY FLOW 07. SELFMONCTORING ❑9. BIENNIAL INTEGRITY TEST(0.1 GPH) GRAVITY PLOW(Chak all that apply): ❑8. DAILY VISUAL MONITORING ❑9. BIENNIAL INTEGRITY TEST(0.1 GPH) SECONDARELY CONTAINED PIPING No I ,(1/; SECONDARILY CONTAINED PIPING �� `n i/�j�� PRESSURIZED PIPING(Check all that apply): 1 Msr"{ PRESSURIZED PIPING(Check all that apply): LJ 7G t!C 10. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL 10. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL ALARMS AND(Cheek one) ALARMS AND(Check one) ❑a. AUTO PUMP SHUT OFF WHEN A LEAK OCCURS ❑R.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 Oc. NO AUTO PUMP SHUT OFF Uc. NO AUTO PUMP SHUT OFF ❑11. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)WITH FLOW SHUT OFF OR RESTRICTION ❑U. AUTOMATIC LEAK DETECTOR ❑12. ANNUAL INTEGRITY TEST(0.1 GPH) [112. ANNUAL INTEGRITY TEST(0.1 GEN) 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(Check all that apply) EMERGENCY GENERATORS ONLY(Check all that 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 [115. AUTOMATIC LINE LEAK DETECTOR (3.0 GPH TEST) WITH011T FLOW SHUT OFF OR RESTRICTIONDETECTOR-(3.0I5.AUTOMATIC LINE LEAK GPH TEST) ❑16. ANNUAL INTEGRITY TEST(0.1 GPH) [116. ANNUAL INTEGRITY TEST(0.1 GPH) ❑17. DAILY VISUAL CHECK ❑17. DAILY VISUAL CHECK VIIL:DISPENSER CONTAINMENT.. DISPENSER CONTAINMENT tag. ❑1. FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE ❑4. DMLYVISUALCFIECK a69. DATE INSTALLED ❑2. CONTINUOUS DISPENSER PAN SENSOR+AUDIBLE AND VISUAL ALARMS [15. TRENCH/LINER MONITORING ❑3. CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR C17 DISPENSER-AUDIBLE AND VISUAL ALARMS NONE IR.O WNER%OPERA9'O'It.S=+A.TURE.. - I certify that the information provided herein is true and accumm to the best of my knowledge. SIGNq, OFOWNER/ ADM DATE: 19111Y NAME OF OWNEIt/QPERA (Imfint): (510 . TITLE OF OWNE VOPERATOR: L aTT' Pemrit Number(Ageay use only) 471. -r t Approved (Ageecy use only) 474. 1 Permit Efpirabou Dam(Agency we only) 475. UPCF hwfwrc-b(1/99)-3/4 kttp-./fw .unidoo.org Rev.02/16/00