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UNIFIED PROGRAM CONSOLIDATED FORM i TANKS UNDERGROUND STORAGE TANKS -TANK PAGE 2 VL PIPING CONSTRUCTION(Check a7 Nal appy) _ - UNOERGROUNO PIPING ABOVEGROUND PIPING SYSTEM TYPE 1.PRESSURE ❑ 2. SUCTION ❑ 3. GRAVrTY ❑ 1. PRESSURE 'tet ❑ 2. SUCTION ❑ ] GRAVITY CONSTRUCTIOW ❑ySINGLE WALL ❑ 3.UNED TRENCH ❑99 OTHER ❑ 1. SINGLE WALL "• 1195. UNKNOWN MANUFACTURER �2.DOU3LE WALL ❑95.UNKNOWN ❑ 2. DOUBLEVIALL 1399. OTHER MANUFACTURER MANUFACTURER ❑ 1.BARE STEEL ❑ 6. FRP COMPATIBLE W7 100%METHANOL ❑ 1. BARE STEEL ❑ 6.FRP COMPATIBLE Wl IC0%METHANOL MATERIALS AND ❑ 2.STAINLESS STEEL ❑ 7.GALVANIZED STEEL ❑ 2. STAINLESS STEEL ❑ 7.GALVANIZED STEEL CORROSION PROTECTION ❑3 LASTIC COMPATIBLE WITH CONTENTS ❑95. UNKNOWN ❑ 3. PLASTIC COMPATIBLE WITH CONTENTS ❑ 6. FLEXIBLE(MOPE) ❑59. OTHER 4.FIBERGLASS ❑ 6.FLE)UBLE(HOPE) ❑99. OTHER ❑ 4. FIBERGLASS ❑ 9, CATMOCIC PROTECTION - ❑ 5 STEELVO COATING ❑ 9.CATHODIC PROTECTICN ❑ 5. STEEL WI COATING ❑95. UNKNOWN VII.PIPING LEAK DETECTION(Check alIDat agpy) _ UNCERGROUNO PIPING ABCVEGROUNO PIPING SINGLE WALL PIPING SINGLE WALL PIPING PRESSURIZED PIPING(Clock al Nat appy): PRESSURIZED PIPING(Check an feat 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,- EAK, :LEAK SYSTEM FAILURE,AND SYSTEM DISCONNECTION-AUDIBLE AND VISUAL SYSTEM FAILURE.AND SYSTEM DISCONNECTION•AUDAUDIBLE AND VISUALALARMS ALARMS ❑ 2.MONTHLY 0.2 GPM TEST ❑ 2. MONTHLY 0 2 GPM TEST ❑ 3. ANNUAL INTEGRITY TEST(0.1 GPM) ❑ 3.ANNUAL INTEGRITY TEST(0 1 GPM) ❑ {. DAILY VISUAL CHECK CONNENTIONAL SUCTION SYSTEMS CONVENTIONAL SUCTION SYSTEMS(Check all that appy): ❑ 5 DAILY VISUAL MONITORING OF PUMPING SYSTEM•TRIENNIAL PIPING INTEGRITY ❑ 5. DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM TEST(0 1 GPM) ❑ 6. TRIENNIAL INTEGRITY TEST(0.1 GPM) SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): ❑ 7.SELF MONITORING - ❑ 7.SELF MONITORING GRAVITY FLOW GRAVITY FLOW(Check an that appy): ❑ 9. BIENNIAL INTEGRITY TEST(0 1 GPM) r _. ❑ 6. DAILY VISUAL MONITORING - . .- ❑ 9. BIENNIAL INTEGRITY TEST(0.1 GPM) SECONOARILY CONTAINED PIPING - SECONDARILY CONTAINED PIPING PRESSURIZED PIPING(Check as brat appy), PRESSURIZED PIPING(Check all that apply): 10.Gt0No OU$TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL ALARMS AND 10,CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL ALARMS AND(Neck one) ❑ a AUTO PUMP SHUT OFF WHEN A LEAK OCCURS ❑ 4.AUTO PUMP SHUT OFF WHEN A LEAK OCCURS ❑0 AUTO PUMP SMUT OFF FOR LEAKS.SYSTEM FAILURE AND SYSTEM ❑ t. AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM CISCONNECTION DISCONNECTION ❑ c NO AUTO PUMP SHUT OFF 1:1c NO AUTO PUMP SHUT OFF 11. AUTOMATIC UNE LEAK DETECTOR(3A GPM TEST)WITM FLOW SHUT CFF OR ❑ 11. AUTOMATIC LEAK DETECTOR RESTRICTION ❑ 12. ANNUAL INTEGRITY TEST(C 1 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 GE"IE.4ATORS CNLY(Check a7 C.at appy) - - EMERGENCY GENERATORS ONLY(Check al that appy) ❑ ta.CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF•AUDIBLE AND ❑ 14. CONTINUOUS SUMP SENSOR VATHCUT AUTO PUMP SMUT OFF•AUDIBLE ANO VISUAL VISUALALARMS - - ALARMS ❑ 15.AUTOMATIC UNE LEAK DETECTOR(3.0 GPM TEST)WITHOUT FLOW SHUT OFF OR ❑ 15. AUTOMATIC UNE LEAK DETECTOR(3.0 GPM TEST) _ RESTRICTION ❑ 16.ANNUAL INTEGRITY TEST(0.1 GPM) ❑ 16. ANNUAL INTEGRITY TEST(0.1 GPM) ❑ 17.DAILY VISUAL CHECK ❑ 17. DAILY VISUAL CH ECK VHL DISPENSER CONTAINMENT OISPENSER CONTAINMENT 1.FLOAT MECHANISM THAT SMUTS OFF SHEAR VALVE ❑ A.DAILY VISUAL CHECK DATE INSTALLED ❑ 2.CONTINUOUS DISPENSER PAN SENSOR-AUDIBLE AND VISUAL ALARMS ❑ 5. TRENCM L'NE.R IMONITCRING ❑ 3. CONTINUOUS DISPENSER PAN SENSOR V11TH AUTO SHUT OFF FOR DISPENSER•AUDIBLE ANO.NISUAL AURINS ❑ 6. NONE DL OWNER.'OPERATOR SIGNATURE 1 ca:aty tnx?a Y+fartnaoon b Ia two and accurate to the test a/my kno�•leope. SIGNATUREG R DATE NAME OF CVQKE7 I TITLE OF OWMEXOPERATTOR R I J c� Punas Nur=er(Fwaocat use only) Penmt AppeoreC(for local use orsy) Pemri Ec•aoan Dake(Forkaeal use only) I CUPAFORM(499) fcrTnetfy S'NRCB Fcl.^..B