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I FIED PROGRAM CONSOLIDATED FO' �%w TANKS UNDERGROUND STORAGE TANKS - TANK PAGE 2 _ VI.PIPING CONSTRUCTION(cnak all than apply) Page of UNDERGROUND PIPING ABOVEGROUND PIPING SYSTEM TYPE ®1.PRESSURE 0 2.SUCTION 0 3.GRAVITY 459, 0 1.PRESSURE CONSTRUCTION/ ❑2.SUCTION ❑3.GRAVITY 459, MANUFACTURER I.SINGLE WALL 3.LINED TRENCH 99.OTHER 460 1.SINGLE WALL 95.UNKNOWN 462. M 2.DOUBLE WALL [195.UNKNOWN 0 2.DOUBLE WALL 0 99.OTHER MANUFACTURER 461. MANUFACTURER 463. ❑1.BARE STEEL 0 6.FRP COMPATIBLE W1100%METHANOL O 1.BARE STEEL O 6.FRP COMPATIBLE W/100%METHANOL ❑2.STAINLESS STEEL 0 7.GALVANIZED STEEL 0 2.STAINLESS STEEL ❑7.GALVANIZED STEEL [13.PLASTIC COMPATIBLE WITH CONTENTS ❑95.UNKNOWN 0 3.PLASTIC COMPATIBLE W/CONTENTS [18.FLEXIBLE(HDPE) [199.OTHER [14.FIBERGLASS ®8.FLEXIBLE(HDPE) [199.OTHER O 4.FIBERGLASS [19.CATHODIC PROTECTION ❑5.STEEL W/COATING [19.CATHODIC PROTECTION 464. 0 5.STEEL W/COATING O 95.UNKNOWN 465. VII.PIPING LEAK DETECTION(check all maz apply)(A descripnw of the monitoring program.hall be submit d m the local egenry.) UNDERGROUND PIPING ABOVEGROUND PIPING SINGLE WALL PIPING a66. SINGLE WALL PIPING 467. PRESSURIZED PIPING(Check all that apply): PRESSURIZED PIPING(Check all that apply): ❑L ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP 01. 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 02. MONTHLY 0.2 GPH TEST ❑3. ANNUAL INTEGRITY TEST(0.1 GPH) 03. ANNUAL INTEGRITY TEST(0.1 GPH) 04. DAILY VISUAL CHECK CONVENTIONAL SUCTION SYSTEMS CONVENTIONAL SUCTION SYSTEMS(Check all that apply) [15. DAILY VISUAL MONITORING OF PUMPING SYSTEM+TRIENNIAL PIPING INTEGRITY TEST(0.1 GPH) 5. DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): [J6. TRIENNIAL INTEGRITY TEST(0.1 GPH) 0 7. SELF MONITORING SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): GRAVITY FLOW 0 7. SELF MONITORING 9. BIENNIAL INTEGRITY TEST(0.1 GPH) GRAVITY FLOW(Check all that apply): ❑8. DAILY VISUAL MONITORING 09. 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 O 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 Dc. NO AUTO PUMP SHUT OFF (3c. NO AUTO PUMP SHUT OFF ® 11. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)WITH FLOW SHUT OFF OR RESTRICTION 011 AUTOMATIC LEAK DETECTOR ❑12. ANNUAL INTEGRITY TEST(0.1 GPH) O 12. ANNUAL INTEGRITY TEST(0.1 GPH) SUCTION/GRAVITY SYSTEM SUCTION/GRAVITY SYSTEM ❑13. CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS [3 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 O 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 SHUT OFF OR RESTRICTION ❑I5. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST) ❑16. ANNUAL INTEGRITY TEST(0.1 GPH) 0 16. ANNUAL INTEGRITY TEST(0.1 GPH) ❑17. DAILY VISUAL CHECK 0 17. DAILY VISUAL CHECK VIII.DISPENSER CONTAINMENT DISPENSER CONTAINMENT 468. [] 1. FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE 4. DAILY VISUAL CHECK 469. DATE INSTALLED C]2. CONTINUOUS DISPENSER PAN SENSOR+AUDIBLE AND VISUAL ALARMS ❑5. TRENCH/LINER MONITORING 2002 ®3. CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR �6. NONE DISPENSER+AUDIBLE AND VISUAL ALARMS IX.OWNERIOPERATOR SIGNATURE 1 certify that the information provided hereinis and accurate o the best of my knowledge. SIGNATURE O TOR DALE: 470. OZ �Z [ /zoo Z NAME OF OVnf91U0PERATOR(print): , ,r / TITLE OF OWNER/OPERATOR: Permit Number(Agency use only) 471 1 Permit Approved By(Agency use only) 474 1 Permit Expiration Date(Agency use only) 475. UPCF hwfwrc-b(1/99)-3/4 h"p://www.unidocs.org Rev.02/16/00