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OJNIFIED PROGRAM CONSOLIDATED FORo 4?) 4.1 7 ANK: TA0515703 PR#: PRO521942 FAC#: FA0014921 UNDERGROUND STORAGE TANKS - TANK PAGE 2 VL PIPING CONSTRUCTION(Chak au that appy) P.,5 ofs UNDERGROUND PIPING ABOVEGROUND PIPING SYSTEM TYPE M L PRESSURE ❑ 2.SUCTION ❑ 3.GRAVITY 458 ❑ I.PRESSURE ❑ 2.SUCTION ❑3.GRAVITY 459 CONSTRUCTION ❑1.SINGLE WALL ❑3.LINED TRENCH ®99.OTHER 469 ❑ I.SINGLE WALL ❑95.UNKNOWN 462 ❑2.DOUBLE WALL [195.UNKNOWN ❑ 2.DOUBLE WALL ❑99.OTHER MANUFACTURER ENVIRON 461 MANUFACTURER 463 ❑ 1.BARE STEEL [16.FRP COMPATIBLE w/1W%METHANOL ❑ I.BARE STEEL [16,FRP COMPATIBLE w/1NA4,METHANOL ❑ 2.STAINLESS STEEL ❑7.GALVANIZED STEEL ❑ 2.STAINLESS STEEL ❑ 7.GALVANIZED STEEL ❑ PLASTIC COMPATIBLE W/CONTENTS ❑ 95.UNKNOWN ❑ PLASTIC COMPATIBLE W1 CONTENTS ❑ 95.UNKNOWN ❑ 4.FIBERGLASS ® 8.FLEXIBLE(HDPE) ❑ )).OTHER ❑ 4.FIBERGLASS ❑ 8.FLEXIBLE(HDPE) ❑ 99.OTHER [:15.STEEL W/COATING ❑9.CATHODIC PROTECTION 464 ❑ 5.STEEL W/COATING ❑ 9.CATHODIC PROTECTION 465 VR.PIPING LEAK DETECTION(Clavi:all Wet Apply)(Ad ptwnofthe mcnitorm8 pmg shall ba mbmittrAto 0c kaal agacv.) UNDERGROUND PIPING ABOVEGROUND PIPING SINGLE WALL PIPING 4M SINGLE WALL PIPING 467 PRESSURIZED PIPING(Cheek all that apply): PRESSURIZED PIPING(Check all that apply): ❑ I.ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP SHOT OFF ❑ 1.ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP SHUT OFF FOR LEAK,SYSTEM FAILURE,AND SYSTEM DISCONNECTION+AUDIBLE AND FOR LEAK SYSTEM FAILURE,AND SYSTEM DISCONNECTION+AUDIBLE AND VISUAL ALARMS. VISUAL ALARMS. ❑ 2.MONTHLY 0 2 GPH TEST ❑ 2.MONTHLY 0.2 GPH TEST ❑ 3.ANNUAL INTEGRITY TEST(O.1 GPH) ❑ 3.ANNUAL INTEGRITY TEST(01 GPH) ❑4.DAILY VISUAL CHECK CONVENTIONAL SUCTION SYSTEMS CONVENTIONAL SUCTION SYSTEMS(Check all that apply) ❑ 5.DAILY VISUAL MONITORING OF PUMPING SYSTEM+TRIENNIEAL PIPING ❑ S.DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM INTEGRITY TEST(0.1 GPH) ❑ 6.TRIENNIAL INTEGRITY TEST(0.1 GPH) SAFE SUCTION SYSTEMS(NO VALUES IN BELOW GROUNDPIPING): SAFE SUCTION SYSTEMS(NO VALUES IN BELOW GROUNDPIPING): ❑ 7.SELF MONITORING ❑ 7.SELF MONITORING GRAVITY FLOW ❑ 9.BIENNIAL INTEGRITY TEST(0.1)GPH GRAVITY FLOW(Check all that apply): ❑ 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 ae) ALARMS AND(Cback one) J A%R�-,.AUTO PUMP SHUT OFF WHEN A LEAK OCCURS ❑ a.AUTO PUMP SHUT OFF WHEN A LEAK OCCURS M 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 1.0 GPH TEST)WITH FLOW SHUT OFF OR RESTRICTION ElI I AUTOMATIC LEAK DETECTOR ❑ 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(Clack all that appy) EMERGENCY GENERATORS ONLY(Clack all thatapply) ❑ 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)WITHOUT FLOW ❑ 15.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 VIR.DISPENSER CONTAINMENT DISPENSER CONTAINMENT ❑ I.FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE ❑4.DAILY VISUAL CHECK DATE INSTALLED 468 ❑ 2.CONTINUOUS DISPENSER PAN SENSOR+AUDIBLE AND VISUAL ALARMS ❑ 5.TRENCH LINER/MONITORING ® 3.CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR ❑6.NONE DISPENSER+AUDIBLE AND VISUAL ALARMS 469 I7(.OWNERIOPERATOR SIGNATURE leeaiy t hue end acmtmm bdM beat ofmY knowlcdg. Sf O E OPE TO �/ DATE 479 i NAME OF OWNER/OPERATOR(p � 47 TITLE OF OWNEIVOPERATOR 472 a PANumber(Forlwuaaonly) 473 Pamit Apptaed(For uscaly) 474 Permit E,waaia D.(F.,lcalumonly) / 475 PT0015325 EE0004006 6/30/2008 12:00:OOAM UPCF(12/99 revised)