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Ah UNIFIED PROGRAM CONSOLIDATED FORM TANK: TA0506493 PRO: PR0231057 FAC#: FAN03720 UNDERGROUND STORAGE TANKS -TANK PAGE 2 VI.PIPING CONSTRUCTION(Chock all that apply) Page 3 of 7 UNDERGROUND PIPING 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 ❑99.OTHER 460 ❑ 1.SINGLE WALL ❑ 95.UNKNOWN 462 �2 IILEWALL ❑ UN . KNOWEl 2.DOUBLE WALL 99.OTHER MANUFACTURER 95 461 MANUFACTURER 163 ❑ 1.BARE STEEL ❑ 6.FRP COMPATIBLE W Its METHANOL ❑ I.BARE STEEL ❑ 6.FRP COMPATIBLE W I NIN.METHANOL ❑ 2.STAINLESS STEEL ❑ 7.GALVANIZED STEEL [12.STAINLESS STEEL ❑ 7.GALVANIZED STEEL ❑ PLASTICCOMPATH3LEW/CONTENTS ❑ 95.UNKNOWN ❑ PLASTIC COMPATIBLE W/CONTENTS [:195 UNKNOWN $I,4.FIBERGLASS ❑ &FLEXIBLE(HDPE) ❑ 99.OTHER ❑4.FIBERGLASS ❑ 8.FLEXIBLE(HOPE) ❑ 99.OTHER ❑ 5.STEEL W/COATING ❑ 9.CATHODIC PROTECTION 4" ❑ 5.STEEL W/COATING ❑ 9.CATHODIC PROTECTION 465 VII.PIPING LEAK DETECTION(Cluck all that apply)(A dmviplim ofinentmitoring progmn than hesabmiuN to the local agemy.) UNDERGROUND PIPING ABOVEGROUND PIPING SINGLE WALL PIPING Ogg SINGLE WALL PIPING 467 PRESSURIZED PIPING(Check all that apply): PRESSURIZED PIPING(Cheek all that apply): ❑ 1.ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP SHUT 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(0.1 GPH) ❑ 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(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 ALARMSAND(C mn) ALARMS AND(Chat mn) a AUTO PUMP SHUT OFF WHEN A LEAK OCCURS ❑a.AUTO PUMP SHUT OFF WHEN A LEAK OCCURS Aqb.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 FLOW 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(Check ell Oat pply) EMERGENCY GENERATORS ONLY(Chock all that apply) ❑ 14.CONTINUOUS SUMP SENSOR WITH UT 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 UT 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 VIIL DISPENSER CONTAINMENT DISPENSER CONTAINMENTIPI'1,FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE 94.DAILY VISUAL CHECK DATEINSTALLED 468 F1 2.CONTINUOUS DISPENSER PAN SENSOR+AUDIBLE AND VISUAL ALARMS ❑ 5.TRENCH LINER/MONITORING -l ❑3.CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR ❑ 6.NONE DISPENSER+AUDIBLE AND VISUAL ALARMS 449 DL OWNER/OPERATOR SIGNATURE I astify On the mOrnaboa prmi4M herein is true aM accmntc to the best ofmy kraalnlc. SIGNATURE OF OWNER/OPERATOR DATE 470 NAME OF OWNER/OPERATOR(print) TITLE OF OWNER/OPERATOR 4]I 472 Patnit Numba(Forlecaluseaoly) 4Y3 Permit APWOYW(For kcal use mJy) 474 Peanut Erpirmim Dmc(Fc kaalusc only) 475 PT0004328 EE0003804 12/31/1996 12:00:OOAM UPCF(12/99 revised)