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ONRFIED PROGRAM CONSOLIDATED FORIM* TANK: TA0508267 PR#: PR0231509 UNDERGROUND STORAGE TANKS -TANK PAGE 2 FAC#: FA0003809 VI.PIPING CONSTRUCTION(cnak an than apply) Paae 79n UNDERGROUND PIPING ABOVEGROUND PIPING SYSTEM TYPE DQ 1.PRESSURE ❑2.SUCTION ❑3.GRAVITY 458 ❑ L PRESSURE ❑2.SUCTION ❑3.GRAVITY 459 CONSTRUC130N ❑I.SINGLE WALL 03.LINED TRENCH ❑ 99.OTHER 460 ❑ 1.SINGLE WALL 1195 UNKNOWN 462 �QLDOUBLEWALL ❑95.UNKNOWN 02.DOUBLE WALL ❑99.OTHER MANUFACTURER A M461 MANUFACTURER k3 ❑ I.BARE STEEL ❑ 6.FRP COMPATIBLE v 100%METHANOL ❑ 1.BARE STEEL ❑6.FRP COMPATIBLE n,/IN%WTHANOL ❑ 2.STAINLESS STEEL ❑ 7.GALVANIZED STEEL ❑ 2.STAINLESS STEEL ❑ 7.GALVANIZED STEEL ❑ PLASTIC COMPATIBLE W/CONTENTS ❑ 95.UNKNOWN ❑ PLASTIC COMPATIBLE W/CONTENTS ❑ 95.UNKNOWN A 4.FIBERGLASS ❑ 8.FLEXIBLE(HDPE) ❑ 99.OTHER ❑ 4.FIBERGLASS ❑ 8.FLEXIBLE(HDPE) ❑ 99.OTHER ❑ 5.STEEL W/COATING ❑ 9.CATHODIC PROTECTION 464 ❑5.STEEL W/COATING ❑ 9.CATHODIC PROTECTION 465 VII.PIPING LEAK DETECTION(0mek all mat apply)(A dwaipEoa nrmemwdtmmapmawm anau he sahmhtwi w the lml nanny) UNDERGROUND PIPING ABOVEGROUND PIPING SINGLE WALL PIPING 466 SINGLE WALL PIPING PRESSURIZED PIPING(Check all that apply): PRESSURIZED PIPING(Check all that apply): 467 ❑ 1.ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP SHUT OFF ❑ '.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 ❑3.ANNUAL INTEGRITY TEST(0.1 GPH) ❑2.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) ❑ S.DAILY VISUAL MONITORING OF PUMPING SYSTEM+TRIENNIEAL PIPING ❑ 5.DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM INTEGRITY TEST(0.1 GPH) ❑ 6.TRIENNIAL INTEGRITY TEST(0.1 GPH) SAFE SUCTION SYSTEMS MO VALUES IN BELOW GROUNDPIPING): ❑7.SELF MONITORING SAFE SUCTION SYSTEMS(NO VALUES IN BELOW GROUNDPIPING): GRAVITY FLOW ❑ 7.SELF MONITORING ❑ 9.BIENNIAL INTEGRITY TEST(0i GPH GRAVITY FLOW(Check all that apply): ❑ B.DAILY VISUAL MONITORING E] 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(Chale mc) ALARMS AND(clack oac) ❑ a.AUTO PUMP SHUT OFF WHEN A LEAK OCCURS ❑ a.AUTO PUMP SHUT OFF WHEN A LEAK OCCURS Kb.AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM ❑I.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 LME LEAK DETECTOR(3.0 GPH TEST)WITH FLOW SHUT OFF OR RESTRICTION ❑ 11.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(Check all that apply) EMERGENCY GENERATORS ONLY(Check a0 Nrt apply) ❑ 14.CONTINUOUS SUMP SENSOR WITHOI IT 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 E] 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 VIII.DISPENSER-Co VrAINMENT DISPENSER CONTAINMENT ❑ I.FLOAT MECHAMSM THAT SHUTS OFF SHEAR VALVE DATE INSTALLED ❑4.DAILY VISUAL CHECK 468 ❑ 2.CONTINUOUS DISPENSER PAN SENSOR+AUDIBLE AND VISUAL ALARMS ❑ 5.TRENCH LINER/MONITORING 13.CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR ❑ 6.NONE 444 ` DISPENSER+AUDIBLE AND VISUAL ALARMS 469 IX.OWNER/OPERATOR SIGNATURE I wtnty that tM1e information pmvidd M1eeia a pun and aH!nnar SI F EDATE470 INAME OFO R/OP BATOR( riot) TITLE QF.QWNER/OPERATOej 471 1' /�I47Permit Nned (For twat me only) 473 Permil AWrovW(1-laws me only) 474 Permit Expiration Date(For local me only) 475 PT0004962 EE0003804 12/31/1998 UPCF(12/99 revised)