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UNIFIED PROGRAM CONSOLIDATED FORM TANKS UNDERGROUND STORAGE TANKS - TANK PAGE'2 VL PIPING CONSTRUCTION(Check a7 that appy) UNDERGROUND PIPING ABOV=_GROUNO PIPING SYSTEM TYPE 1 PRESSURE ❑ 2. SUCTION ❑ 3 GRAVITY ❑ t. PRESSURE ❑ 2. SUCTION ❑ ]. GRAVITY CONSTRUCTIOW ❑ ty^""LEWALL ❑ 3. LINED TRENCH ❑99 OTHER ❑ I. SINGLE WALL -' - ❑95.UNKNO-AM MANUFACTURER 2. DOUBLE WALL ❑95. UNKNOWN ❑ 2. DOUBLE WALL 1199.OTHER MANUFACTURER MANUFACTURER . ❑ 1.BARE STEEL ❑ G. FRP COMPATIBLE W7 ICO%METHANOL ❑ 1. BARE STEEL ❑6.FRP CCMPATIBLE W/ICOM.METHANOL MATERIALS AND ❑ 2.STAINLESS STEEL ❑ 7.GALVANIZED STEEL ❑ 2. STAINLESS STEEL CORROSION ❑7.GALVANIZED STEEL PROTECTION 113.,t_CASTIC COMPATIBLE WITH CONTENTS ❑95. UNKNOWN ❑ 3. PLASTIC COMPATIBLE WITH CONTENTS 136. FLEXIBLE(HDPE) ❑S9.OTHER L 4.FIBERGLASS ❑ 5. FLEXIBLE(HOPE) ❑99. OTHER ❑ 4, FIBERGLASS ❑9. CATMCCIC PROTECTION ❑5 STEEL W/COATING ❑ 9.CATHODIC PROTECTION ❑ 5. STEEL W/COATING ❑95. UNKNOWN VII.PIPING LEAK DETECTION(Check iC mat aGP/Y) SINGLE WALL PIPING UNOERGROUNO PiPINIC ABOVEGROUND PIPING I PRESSURIZED PIPINGSINGLE WALL PIPING (C/IecF as Nat appy): PRESSURIZED PIP;NG(Check an mat apply): ❑ 1. ELECTRONIC UNE LEAK DETECTOR 3.0 GPM TEST WITH AUTO PUMP SMUT OFF FOR ❑ 1. ELECTRONIC UNE LEAK DETECTOR 3.0 GPM TEST WITH AUTO PUMP SMUT OFF FOR LEAK, :LEAK,SYSTEM FAILURE,AND SYSTEM DISCONNECTION•AUDIBLE AND VISUAL SYSTEM FAILURE.AND SYSTE ALARMS U M DISCONNECTION;AUDIBLE AND VISUAL 112. MONTHLY 0 2 GPM TEST ❑ 2.MONTHLY 0.2 GPM TEST , ❑ ❑ ].ANNUAL INTEGRITY TEST(0 1 GPM) 3. ANNUAL INTEGRITY TEST(0.1 GPM) ❑ 4. DAILY VISUAL CHECK COPNENTIONAL SUCTION SYSTEMS _ CCNVENTIONAL SUCTION SYSTEMS(Check admaf appy): ❑ S DAILY VISUAL MONITOR1tIG OF PUMPING SYSTEM•TRIENNIAL PIPING INTEGRITY ❑ 5. DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM TEST(0 1 GPM) ❑ G. TRIENNIAL INTEGRITY TEST(0.1 GPM) SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUNO PIPING): ❑ 7.SELF MONITORING - ❑ 7. SELF MONITORING GRAVITY FLOW GRAVITY FLOW(Check an mat appy): C19. BIENNIAL INTEGRITY TEST(O1GPM) _ ❑ 6. DAILY VISUAL MONITORING ❑ 9 BIENNIAL INTEGRITY TEST(0.1 GPM) _ SECONDARILY CONTAINED PIPING SECONDARILY CONTAINED PIPING PRESSURIZED PIPING(Check aumat apply) - PRESSURIZED PIPING(Check ail Nat appy): (Cr to one) t0. C rtooVS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL ALARMS AND 10.CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL AURAS AND(ct+eCk ane) one) ❑ Is AUTO PUMP SHUT OFF WHEN A LEAK OCCURS ❑ i AUTO PUMP SHUT OFF WHEN A LEAK OCCURS 0 AUTO ESMUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEMDISCONNNNECTION ❑ 0. AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM DISCONNECTION C ATOMATIC c NO AUTO PUMP SHUT OFF ❑ C NO AUTO PUMP SMUT OFF UNE LEAK DETECTOR(3.0 GPM TEST)WITH FLOW SMUT CFF OR ❑ 11. AUTOMATIC LEAK DETECTOR RESTRICTION ❑ 12. ANNUAL INTEGRITY TEST(0 I GPM) ❑ 12.ANNUAL INTEGRITY TEST(0.1 GPM) SUCTIONIGRAVITY SYSTEM SUCTIOWGRAVITY SYSTEM; ❑ 13 CONTINUOUS SUMP SENSOR•AUDIBLE AND VISUAL ALARMS ❑ 13. CONTINUOUS SUMP SENSOR•AUDIBLE AND VISUAL ALARMS EMERGENCY GENERATORS ONLY(Gfeck a7 Cat appy) EMERGENCY GENERATORS ONLY(Chock as mat appy) ❑ 14.CONTINUOUS SUMP SENSOR WITHOUT ALTO PUMP SHUT OFF•AUDIBLE AND ❑ 14. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SMUT OFF•AUDIBLE ANO VISUAL VISUALALARYS ALARMS ❑ 15.AUTOMATIC UNE LEAK DETECTOR(3.0 GPM TEST)WITHOUT FLOW SHUT OFF OR ❑ 13. AUTOMATIC UNE LEAK DETECTOR(].0 GPM TEST) RESTRICTION ❑ 16.ANNUAL INTEGRITY TEST(0.1 GPM) ❑ 16. ANNUAL INTEGRITY TEST(0.1 GPM) ❑ 17.DMLYVISUALCMECX ❑ 17• DAILY VISUAL CHECK VUL DISPENSER CONTAINMENT OISPENSER CONTAINMENT FLOAT MECHANISM THAT SHUTS OFF SMEAR VALVE ❑ 4.DAILY VISUALCMECK DATE INSTALLED ❑ 2.CONTINUOUS DISPENSER PAN SENSOR.AUDIBLE AND VISUAL ALARMS ❑ S.TRENCH LINER/MONTCRING ❑ 3. CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SMUT OFF FOR DISPENSER+AUDIBLE AND VISUAL ALARMS ❑ d. NCNE DC OWNER)OPERATOR SIGNATURE 1 t aroty roar me r,lamaodn prmridea t• �tole and acuate to me best of my kravedgs. SIGNATURE OF OWN R DATE ._ NAME OF CWN A, TITLE OF OWNER.CPERATCR i Penh N%A=W(Fore=st We only, Peanut Approved(For/oca/use ormy) I Pemvt E xzmn Dan(Foetca/we only) CUPAFORM(499) F-r reny SWRC6 FCt^c