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1 FLED PROGRAM CONSOLIDATED FO! TANKS UNDERGROUND STORAGE TANKS - TANK PAGE 2 Page_of VI.PIPING CONSTRUCTION(Check all that apply) UNDERGROUND PIPING I ABOVEGROUND PIPING SYSTEM TYPE ®1.PRESSURE ❑2.SUCTION ❑3.GRAVITY 458 1 0 1.PRESSURE ❑2.SUCTION ❑3.GRAVITY 459. CONSTRUCTION/ 0 1.SINGLE WALL ❑3.LINED TRENCH ❑99.OTHER ab9. ❑I.SINGLE WALL ❑95.UNKNOWN 462. MANUFACTURER ®2 DOUBLE WALL O 95.UNKNOWN ❑2.DOUBLE WALL ❑99.OTHER MANUFACTURER 461. MANUFACTURER 463' O 1.BARE STEEL ❑6.PEP COMPATIBLE W/100%METHANOL ❑LEASE STEEL ❑6.FRP COMPATIBLE W/100%METHANOL 0 2.STAINLESS STEEL ❑7.GALVANIZED STEEL ❑2.STAINLESS STEEL ❑7.GALVANIZED STEEL [13.PLASTIC COMPATIBLE WITH CONTENTS ❑95.UNKNOWN ❑3.PLASTIC COMPATIBLE W/CONTENTS ❑8.FLEXIBLE(HDPE) ❑99.OTHER ❑4.FIBERGLASS ®8.FLEXIBLE(HDPE) ❑99.OTHER ❑4.FIBERGLASS ❑9.CATHODIC PROTECTION 0 5.STEEL W/COATING ❑9.CATHODIC PROTECTION 460. ❑5.STEEL W/COATING ❑95.UNKNOWN 465. VII.PIPING LEAK DETECTION(Chock all that apply)(A description ofthe nimitaing program shall a suhminMto the local Weary.) UNDERGROUND PIPING ABOVEGROUND PIPING SINGLE WALL PIPING 466. SINGLE WALL PIPING 467. PRESSURIZED PIPING(Check all that apply): PRESSURIZED PIPING(Check all that apply): ❑1. ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP ❑1. ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP SHUT-OFF FOR LEAK,SYSTEM FAILURE,AND SYSTEM DISCONNECTION SHUT OFF FOR LEAK,SYSTEM FAILURE.AND SYSTEM DISCONNECTION +AUDIBLE AND VISUAL ALARMS. +AUDIBLE AND 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) 04. DAILY VISUAL CHECK CONVENTIONAL SUCTION SYSTEMS CONVENTIONAL SUCTION SYSTEMS(Check all that apply) ❑5. DAILY VISUAL MONITORING OF PUMPING SYSTEM+TRIENNIAL PIPING 05. DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM INTEGRITY TEST(0.1 GPH) SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): ❑6. TRIENNIAL INTEGRITY TEST(0.1 GPH) ❑7. SELF MONITORING SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): GRAVITY FLOW ❑7. SELF MONITORING 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 one) ALARMS AND(Check one) ®a. AUTO PUMP SHUT OFF WHEN A LEAK OCCURS ❑a. AUTO PUMP SHUT OFF WHEN A LEAK OCCURS ®b. AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM ❑b. AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM DISCONNECTION DISCONNECTION Oc. NO AUTO PUMP SHUTOFF C]c. NO AUTO PUMP SHUT OFF ®11. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)WITH FLOW SHUT 0 11 AUTOMATIC LEAK DETECTOR OFF OR 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 O 13. CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS EMERGENCY GENERATORS ONLY(Check all that apply) EMERGENCY GENERATORS ONLY(Check all that apply) []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 0 15. AUTOMATIC LINE LEAK DETECTOR (3.0 GPH TEST) WITHOUT FLOW 0 15. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST) 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 CONTAINMENT DISPENSER CONTAINMENT 468. [E] 1. FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE ❑4. DAILY VISUAL CHECK 469. DATEINSTAI 02. CONTINUOUS DISPENSER PAN SENSOR+AUDIBLE AND VISUAL ALARMS 05. TRENCH/LINER MONITORING 2002 ®3. CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR []6. NONE DISPENSER+AUDIBLE AND VISUAL ALARMS IX.OWNER/OPERATOR SIGNATURE I certify that the information provided herein d accurW to the best of my knowledge. SIGNATURE OF TO DATE: fJ Z Z Z / C;07- 4m. NAME OF OWNEIUOPERATOR(print); ` �j nn�C TITLE OF OWNER/OPERATOR //;V,r ;hC O 72. Permit Number(Agency use only) G 473. )Permit Approved By(Agency use only) 474. Permit Expiration (Agency Date(Agey use only) 475. UPCF hwfwrc-b 0/99)-3/4 http://www.unidocs.org Rcv.02/16/00