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UNIFIED PRpGRdil4i CONS4LIIIATEI)FURM <br /> TAINKS <br /> -J ERGRC3LTN STORAGE WANKS--- T <br /> ANK PAGE.2 <br /> P8 e <br /> UNDERGROUND PIPLIVG k W'13[ x, <br /> r of <br /> SYSTLrl4!TYPE ].PRESSURE .nom <br /> CONSTRUCTION! ©7-'SUCTION 0 3.GRAVITY 458 ABOVEGROUND PIPING <br /> ❑L SINGLE WALL I L PRESSURE Q 2.SUCTION <br /> MANLrBACTURRIt ❑3.LINED T1tE1ICH ❑3.(JRAvriw a54, <br /> Q 9S.OTHER 466. ❑1.SIN(IIE WALL <br /> y 2.DOUBLE WALL 0 95.UNKNOWN []95.UNKNOWN <br /> MANUFACTURTIR [12.DOUBLE WALL ate' <br /> ❑99.OTHER <br /> Q L BARE 91-EEL V_6.ERP COMPATIBLE W/10046 461. MANUFACTURER _ <br /> ❑2.STAENLESS STEEL SOL ❑1.BARE STEEL 163. <br /> []7.f3ACOX71,MT STRPL ❑6.FRP COMPATIBLE W/]0096 METHANOL <br /> ❑3,PLASTIC COMPATIBLE WITH COTS []2.Sl'AINLESS S'I13EL <br /> ❑95.IL3 7,GALVANIZED STEEL <br /> ❑d FIRFRGLASSUNKNOWNEl3.PLASTIC COMPATIBLE WYCt7NTENtS <br /> ©8.FLEXIBLE(HDPE) Q 99.OTHRR ❑4.FIAERGLASS ❑®•FLEXIBLE(11DFE) Q 49,OTF]ER <br /> ❑3.S'EBL WICOATING ❑9.CATI;ODIC PROTECTION ❑9.CATHODIC PROTECTION <br /> 4M- Q 5 STER1 WICCIATING <br /> -__. ❑95.UNKNOWN <br /> UNDERfiROilNb PIPING R . -- 465. <br /> SINCLE WALL,PIPTIYG aae - ,, W_-.. w <br /> PRESSURIZED PIPING(Chal-all rite[ 4" <br /> SINGLE WALL PIPING ABOVEGROUND P1P[.tiG <br /> ❑i, ELECTRONIC LINE LEAK DETECTOR 3.0 GPM TEST 467. <br /> PRESSURIZED PIPING(Check all that apply); <br /> SIKH'-OFF FOR LEAK,SYSTEM FAILURE,AND SYSTEMtDISO NN T ISP ❑1. ELECTRONIC L"V LEAKDETIJCTOR 3.0 GPIs TEST W <br /> +RUMBLE AND VISUAL ALARMS. SHUT OFF FOR LEAK,SYSTEM FAIL URE,AND SYSTEMMCp ON <br /> O2. MONIIILY 0.2 GPH TEST +AUDIBLE AND VISIIA1 ALARMS <br /> C33' ANNUAL INTEGRITYTEST(O.1 GPH) t ❑ MONT-'Ly 0.2(}PH TEST <br /> 1"' A 01. ANNWAL D`J7EGR1TY TEST(0.1 GPt1) l <br /> C'0NV1IN-nONAL SUCTION SYSTEMS ❑4- DAILY VISUAL CHECK P t <br /> ❑5. DAILY VISUAL MUNUORING OF PUMPING SYSTEM+TRIENNIAL CONVENTIONAL SUCTION SYSTEMS(Cl,cck all that apply) <br /> SAFE 9 <br /> �TTF Y TEST(0.1 [} PSC' 135, DAILY VISUAL MONIT'ORINO OF PIPING AND PUMPING SYSTEt'lSUCTIONON ON SYSTEMS(NOO VALVES IN BELOW GROUND PIPING): <br /> ❑7• SELF MONITORING [16. TRIENNIAL INTEGRITY TEST(at GPH) <br /> GRAVITY FLOW SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GKOUNID PIPING); <br /> E19, 8lENNTAL 1NTLG1UTY'1EST(O,1 GPH) 07. SELF MONI MRING <br /> GRAVITY FLOW(Check an that apply); <br /> ❑1I. DAILY VISUAL.MONITORING <br /> SECONDARILY CONTAINED.PIPING ❑9• BIENNIAL I]YTBGRITY TEST(O.1 GPH) <br /> PRESSURIZED PIPING(Check all that apply): SECONDARILY CONTAINED PIPING. <br /> 10. CONTINUOUS y): PRESSURIZED PIPBNG(Check all that a <br /> TURBINE SLLISF SENSOR - TIj AUCIBLE AND VISUAL 10. CONTMUOUS TURBINE SUMPPSENSOR <br /> ALARMS AND(C3lerkotte) WITH AIIDMLI- <br /> []a. AUTO PUMP SHUT OFF WHEN A LEAK OCCURS ALARMS AND{Check one} ANI) VISUAL <br /> ❑b.AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM ❑a. AUTO PUMP SHUT OFF WHEN A`L11AK OCCURS <br /> DISCONNECTION ❑b.AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM <br /> ❑C. NO AUTO P{tMP SHUT DFF DISCONNECTIOW <br /> Q i L AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST ❑e NO AUTO PLIMP SHUT OFF <br /> OFF OR RESTRICTION )]�313 FLOW SHUT <br /> ❑11. AUTOMATIC LEAK DBTECTOR <br /> [112. ANNUAL INTEGRITY TEST(0-1 GPH) <br /> F]SUCTIONGOAVITYSYMM aa.ANNUAL RtTFt1RITYTEST(I:),l4PH) <br /> (SUCTIOMGRAVTTY SYSTEM <br /> ]3. COIv'IiNU0U5SUMP SENSOR+AUDIBLE AND VISUAL ALARI4iS ❑13. CONTIh't;OUSSUMP SBNSOR+AUDIBLE AND VISUAL ALARMS <br /> EMERGENCY GENERATORS ONLY(CJfxk all that apply)SUMP SENSOR R7THOIi EMERGENCY GENERATORS ONLY(Check all that apply) <br /> []14. CON <br /> AUDIBLEDIBLE AANN D VISUAL ALARMS ['AUTO PUMP SHUT OFF �]14.CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SH(1TOFF <br /> ❑15. AUTOMATIC LINE LEAK, DETECTOR (3.0 GPI4 TEST) 1i'M OV FLOWAUDIBLE AN17 VISUAL ALARMS <br /> SHUT OFF ORRESIiLC'IION �15.AUTOMATIC LINE LEAK p$-IECTOR(3.0 GPH TE <br /> 1316- ANNUAL INTEGRITY TEST(0-1 GPM Ll 16.ANNUAL INTEGRITY TEST(0.1 GPH) ST) <br /> [117, DAILY VISUAL CHECK <br /> -- _ Q 17-DAILY VISUAL CHECK <br /> Ott. - <br /> DISPEIJSFR CONT AITJMENT sea. AI. PLOAT MECFLANISM THAT SH1:TS OFF SHEAR VALVE <br /> DATE INSTALLED2 Ctp�1 r 11 4. DAILY VISUAL CHECK 469 ' <br /> ❑ CONTINUOUS DISPENSER PAN SENSOR+AUDIBLE AND VISUAL ALARMS 115, TRENCH+LMIERMONITORING <br /> ©3. CONTTNUOITS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR <br /> D13PEM1ISIR+AUDLBLF AND VISUAL ALARMS ❑6. NONE <br /> I certify that a Imation provided hereat is true and ec0urate ut the best ofttty knowledge. '` <br /> SIGMA 0 O OPE TO <br /> (��,NAME OF OWh J E TOR DATE: `f 470 <br /> (pri4tJ; <br /> ty ( TITLE OF Oi TO 472. <br /> Ptxmit Number(Agency use duly) 4T3, Petmit1 Ir <br /> AplRoved By(Agercy age only) 474. ernlil F <br /> J piration pate(Agency use milt) 475. <br /> 'VPCF hwAvre-d(1199)-314 <br /> http:1frvww.unid0cs.a rg <br /> Rev.02/16100 <br /> E •d <br /> Xdd l3Cd3SU-1 dH WdE T =E 9002 To idb <br />