BILLING_PRE 2019 - Laserfiche WebLink

Home Browse Search

TANK: TA01028W IFIED PROGRAM CONSOLIDATED FORM '"f, P, PR a: PR0231018 %a FAC 8: FA0003811 UNDERGROUND STORAGE TANKS -TANK PAGE 2 Ito VL PIPING CONSTRUCTION(Check all that apPly) Page 3 013 UNDERGROUND PIPING ABOVEGROUND PIPING 459 SYSTEM TYPE 1.PRESSURE ❑2.SUCTION ❑ 3.GRAVITY 458 ❑ 1.PRESSURE 2.SUCTION ❑ 3.GRAVITY 462 CONSTRUCTION ❑I_SINGLE WALL ❑3..LINED TRENCH ❑ 99.OTHER 4- 1.SINGLE WALL❑ 2.DOUBLE WALL ❑ 95 UNKNOWN OTHER WN M 2.DOUBLE WALL ❑95.UNKNOWN 461463 MANUFACTURER MANUFACTURER ❑ I.BARE STEEL � 6.FRP COMPATIBLE wt]00°/.METHANOL ❑ 1.BARE STEEL [:16.FRP COMPATIBLE N!IUU'�«METHANOL ❑2.STAINLESS STEEL ❑ 7.GALVANIZED STEEL [-12.STAINLESS STEEL [37.GALVANIZED STEEL ❑.PLASTIC COMPATIBLE W/CONTENTS n 95_UNKNOWN ❑ PLASTIC COMPATIBLE W!CONTENTS ❑ 95.UNKNOWN [:j4.FIBERGLASS ❑ 8.FLEXIBLE(HDPE) F-149.OTHER ❑ 4.FIBERGLASS ❑ 8.FLEXIBLE(HDPE) '❑ 99.OTHER . 464 ❑ 5.STEEL W/COATING ❑9.CATHODIC PROTECTION 465 F1 5STEEL W/COATING E]9.CATHODIC PROTECTION VII.PIPING LEAK DETECTION(Check all that apph)(A description of the monitoring Program shall be submitted to the local ageneY.l UNDERGROUND PIPING ABOVEGROUND PIPING SINGLE WALL PIPING 466 SINGLE WALL PIPING 467 PRESSURIZED PIPING(Check all that apply): PRESSURIZED PIPING(Check all that apply): ❑ I.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) 4. 3.ANNUAL INTEGRCTY TEST(0.1 GPA) 1 ❑V DAILY VISUAL CHECK CONVENTIONAL SUCTION SYSTEMS(Check all that apply) CONVENTIONAL SUCTION SYSTEMS 5.DAILY VISUAL MONITORING OF PUMPING SYSTEM+TRIENNIE4L 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 ALARMS AND(Chak nrte) ALARMS AND(Cheek one) ❑ a_AUTO PUMP SHUT OFF WHEN A LEAK OCCURS ❑ e.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 ��/ X.. NO AUTO PUMP SHUT OFF E] c. NO AUTO PUMP SHUT OFF I (RESTRICTION AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)WUR FLOW SHUT OFF OR ❑ 11.AUTOMATIC LEAK DETECTOR T_RESTRICTION M 12.ANNUAL INTEGRITY TEST(0.1 GPH) ❑ 12.ANNUAL INTEGRITY TEST(0.1.GPH) SUCTIONIGRAVTIY SYSTEM SUCTION/GRAVFTY SYSTEM ❑ 1.3.CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS ❑ 13.CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS EMERGENCY GENERATORS ONLY(Chcsk dl that apply) EMERGENCY GENERATORS ONLY(Chink dl thin oppW) ❑ 14.CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF• ❑ 14.CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUTOFF AUDIBLE AND VISUAL ALARMS AUDIBLE AND VISUAL ALARMS ❑ 15.AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)WITHOUT 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 VM.DISPENSER CONTAINMENT DISPENSER CONTAINMENT FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE 4.DAILY VISUAL CHECK DATE INSTALLED 468 2.CONTINUOUS DISPENSER PAN SENSOR+AUDIBLE AND VISUAL ALARMS ❑ 5.TRENCH LINER/MONITORING b�)�,I ❑ 3.CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR ❑ 6.NONE b ll DISPENSER+AUDIBLE AND VISUAL ALARMS at'" IX.OWNERIOPERATOR SIGNATURE I-ft,that the information provided herein u true and accurate to the hest of m kn vledge. TU_RE OF OOPERATOR DATE 1 C 470 `- 5- Q -7 NAME OF OWNER/O EKATOR(Print) TITLE OF OWNER/OPERATOR i,, C 5 471 �Af 10 471 'AkdS C L 472 Pvntit Numbcc I For total use oN_v) 473 Permit Approved(For local use onh) 474 Permit Expiration Dal.(F.r!Deal ince-n t ::11 PT0004970 EE0003 804 12/31/1993 12:00:OOAM UPCF(12199 revised)