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r 0 Z11VCF[-PROGRAM CONSOLIDATED FORM `U TANKS UNDERGROUND STORAGE TANKS - TANK PAGE 2 UNDLRGRGUND PIP17uG t iLle 1� ;r apt t P G of SYSTEM TVP][ a,.in .,,. ` ;a. "Y; I. NG ❑2.SUCTION ABOVEGR3L)NDP IPIN(r CONMUCTIONJ ❑3-GRAVITY 459, []1°PRESSURE hIANUFACTURCR ❑I.SrNGLE WALL ❑3,LVED TRENCH ".OTHER ❑ .StTCTlON 113.GRAVITY qyl C7�.UTHER a6c ❑1-SINGLE WALL �.DOUI3LI WALL ❑95,CJNKRIOWN ❑95 UNKNOWN ❑2.DOUBLE WALL 4A2. MANUNACTIIR$R ❑99.OTHER []I-RARE STEELFRP COM PATIBLE W/[I)q i�jp•jIIANOL 461 MANUFAC"7UKER ❑2.STAINLESS STEEL ❑1.BARD;STEEL "3. ❑7,GALVANIZED STEEL ❑6,FRP COMPATIBLE W110f}%MrTHANOL ❑3.PLASTIC COMPATIBLE.WITH CONTENTS ❑2'STAINLESS STEEL []95.UNKNOWN (]3.PLASTIC COMPATIBLE W!CONTENT'S ❑7.GA FLEXIBLE +HEED STEEL ❑4 FIBERGLASS ❑B.FI.E7(IBLE(HOPI:) ❑S,FLEXIBLE{Hc7PE) ©S STFEL W/COATING ❑99_OTHER ❑a,FIBERGLASS 099.OTHER t - ❑9.C�STH011IC PROTECTION ❑9.CATHODIC PROTECTION' ..-_ 4b9. OATJNO SINGLE WALL PIPING C]s sTGEL w�c ❑vs.LvK aG{YN 465 UNDERGROUNDklteek.al ilsprapplyl n:'esen�y ING P1Y1NG o et 13QVv iitalri�� I ... tr a r r t PRESSURIZED PIPING(Chc� all That a SINGLE%A, PIPING ABOVJ GROUND PIPING ❑1. ELECTRONIC LINE LEAK DETEECT)OR 3.0 GPH TEST WITH AUTO pUhjp PRESSURIZED PIPING(Check all that apply): 467. SHUT-OFF FOR LEgY,,SYSTEM FAILU ❑1. ELECTRONIC LfNE LEAK DETEOR 3.0 GPH TES'I•H TII AUTO PUMP +AUDIBLE AND VISUAL ALARAIS, AND S�S DIS ONNPC77ON SHUT OFF FOR LEAK,S YSTEM FAILURE,AND 5YSTL1 DISCONNKCTION ❑2. MONTHLY 02 GPH TEST AUD18LE AND VISUAL ALARM& ❑3. ANNUAL INTEGRI I'Y TFST jo.1 GPH) �1 0 2 MONTI ILY 0.2 GPI{TEST C]3. ANNUAL INTEGRITY TEST(0.1 GPH} d j� CONVENTIONAL SUCTION SYSTEMS 04. DAILY VISUAL CHECK ❑5, DAILY VISUAL MONITORING OF PtIMP1NG SYSTEM*TR1F.h7N[AL PIPING CONVENTIONAL SUCTION SYCTEMS(Check all that a INTEGRITY TEST(0.1 GPH) J}11Iy) ❑S. DAILY VISUAL MUN[TORING OF PIPING AMID P<(MPI;VG SYSTEM SAFE 5UCT10N SYSTEI113(NU GROUND BELOGROUND PIPING); ❑7, SELF MONITORING 06 TRIENNIAL INTEGRITY TEST(a.I GPH) GRAVITY FLOW SAFE SUCTION SYSTEMS(No VALVES IN BELOW GROUND PIPING): ❑9• BIENNIAL INTEGRITY TEST'(0.1 GPH) 0 7. SELF MONITORING GRAVITY FLOW(Check all that apply): 0 8. DAILY YJSUAL MONITORING SECONDA.RILYCONTAINED PIPING 119, BIENNIAL,INTEGRITY TEST(a•1 GPH) PRESSURIZED PIPING(Check all 1het1 SECONDARILY CONTAINED PIPING 1o. CONIINUOUS TURBINE SUhIpPSENSOR T PRE"SuIIO�vPIPING(Check eJl that a ALARMS AND(Cleck one) _ AUDIBLE AND VISUAL 10. CONTINUOUS TURBINE 5UA4P SENSOR❑a. AUTD PUMP SHUT OFF WHEN A LEAK OCCURS ALAXMS AND(Check one) WITH AUDIBLE AND VISUAL ❑b. AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM ❑a.AUTO PUMP,SHUT OFF W HEN A LEAK OCCURS DISCONNECTION ❑b-AUTO PUMP SHUT OPN',OR L ❑ EAKS,SYSTEM FAILURE AND SYSTEM Oil NO AUTO PUMP SHUT OFF DISCONNECTION 1711. AUTOMATIC LINE LEAK DLTECTOR(3.0 OPH TEST Cc. NO AUTO PUMP 51 RUT UFF OFF OR RESTRICTION )WIfH FLOWSHUT 0 12. ANNUAL rNTFCRTTY TEST(0.1 GPH) ®11. AUTOMATIC LEAK DETECTOR SVCTION/GRAVITY6YSTEM n 12. ANNUALlNTFGRITYTEST 10.I GFH) ❑13. CON'I'INUOU5 SUMP SENSOR*AUDIBLE AND VISUAL ALARMS SUCTION/GIERAVTTY SYSTEM EMERGENCY GVNF.RATORS ONLY(Check all that a 1 [113. CONTINUOUS S4711?SENSOR*AUDIBLE AND VISIJAL ALARMS ❑ IT rONTINUOUS-SUMp SENSOR WITHOI I P AUTO PUMP SHUTOFT ENIFRGRNCY GENERATORS ONLY(Cheek alt that e 1 AUDIBLE AND VISUAL ALARMS ❑14, CONTINUOUS SUMP SENSOR WITH U AUTO P C315. AUTOMATIC LINE LEAK DfETF.CTOR (3A GPI{ TES AUDIBLE AND bISUAI.ALARiN15 T SMP SHUT OFF SHUT•OFF OR RESTRICTION VITHOUT FLOW ❑I6. ANN UAL INTEGRITY TESTA 1 GPH) O 15, AUTOMAI'JC'LIN!~LtAK DETECTOR(3,0 GPEI TEST) �] 17. DAILY VISUAL CHECK C7 16, ANNtdALINTEGRtTY TES7'(0.1 Gprl) r - 1317 DAILY VISUAL CHECK DISPENSER CONTAINMENT 46p. �1 FLOATMECHANlSMTI-Igr�[iUTSUFFSHEARVALVE DATE INSTAJ ITT) >: ._ . - .•r.... � f.:! - ❑ CGNTINUQUS D15p1=NSGR PAN SENSOR AUDIBLE ANt1 VjSUAL ALARMS DAILY VISUALCHECK 469, ❑3• CONTTYUQUS DISPENSER PAN SENSOR WITH AUTO SHUT UFF FOR ❑5 TRENCH/LINER MONJTORING :. UECPFN'SFR+AITOIBLE A1�D VISUAL ALARMS 0 6. NONE I carti tat the tnfmmation pruvlded herein is true and accurate tOD the best o SIGNr3YT3II.O =; �iTIJRF i` 1 Rt OF UWNERIOP T R f my knowledge. I DATE: NAME OF DIV OFERh � 1�_ 1q 370. �r =�f'� TME OFOW RR/OPEkATOR. a?2. Permit umber(Agency ase only) 'a'/L� Femmmt Apprevnl BY(Agency use only) a3a Pennsk Exparatian Date(Agency use only) 475_ LTCF hwiwrc-6�V")-3/4 h ttp;/fwww.U n i d0 rs.o rg Rev.92116MO s •d XLH 13CN3SIJ-1 dpi WdST :E 9002 Te jd0