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w <br /> UNTRED PROGRAM CONSOLIDATED FORNI <br /> TANKS <br /> UNDERGROUND STORAGE TANKS TANK PAGE 2 <br /> PIE <br /> LLNUk'LtCrK(?UNC YfYINti <br /> i <br /> SYSTEIVI7'1'Pl PRESSURE []2.SUCTIONAROVEGROUND PIPING <br /> CONSTRUI TIO V! - ❑3,GRAVITY 451 ❑ 1.PRESSURE Cj 2.SUCTION <br /> li'tA]tiUFACTUREIL ❑�'�I.SINGLE WALL ❑3.LINED TRENC31 ❑D9.OTHER 460 ©3.@RAVITY OP. <br /> 1�.DOUBLE WAIL F195.LJNI(]YOWN Q r SINGLE WALL [�95,UNKNOWN 462. <br /> MANUFACTURER ❑2 DOUBLE WALL p 99 OTHER <br /> �]1.BARE STEEL 461 MANUFACTURER <br /> FRP COMPATIBLE W;10®%METHANOL ❑ 1.BARE STEEL -1` <br /> ❑2.STAINLESS 5TEE_L ❑7.GALVANIZED STEEL U fi FRP COMPATIBLE WiI00%METHANOL <br /> []3.PLASTIC COMPATIBLE WITH CONTENTS 0 2 STAINLESS STEEL U 7.GALVANIZED STEEL <br /> Q 93.UNKNOWN ❑3,PLASTIC COMPATIBLE W!CONTENTS ( } <br /> []4.FIBERGLASS ❑S.FLEXIBLE(HDP EI ❑49.OTHER ❑R.FLFX113LLI HDPE ❑99.OTHER <br /> []5 SFJ kL W/COATING ❑A.PIHER WICO ❑9,CATHODIC PROTECTION <br /> 4r�a, ❑S STEEL WICpAriNG <br /> 9,CATTIODSC PR07E(.TION <br /> il_r -' � � ...s'itt a- i�1�.C�VT� � _�-" ❑43 UNKNOWN <br /> �'[heck�IltkatapA k 9.,.�w ass <br /> llNDERGRDUNDPLPING -- D1FGTi6IIlI1hplii'-. tLooahelltiea°bi " <br /> SINGLE WALL PIPING -1111N1D PIPING <br /> PRESSURIZED PMNG(Check all drat apply). 466 SINGLE WALL PIPING <br /> PP Y) PRESSURIZED PIPING(Check all That 1 467 <br /> ❑1. ELECTRONIC LINE LEAK DETECTOR 3.0 GPH 7-ST WITH AUTO PUMP I. aPFY)� <br /> SHUT-OFF FOR LEAK SYSTEM FAILURE,AND SYSTEM DISCONNECTION ❑ ELECTRONIC LINE LEAK DHTEC70R].0 GPH TES WTTH AUTO PUMP <br /> +AUDIBLF AND VISUAL ALARMS. SHUT OFF FOR LEAK,SYSTEM FAILURE,AND SYSTEM DISCONNECTION <br /> 132. MONTHLY 0,2 OPH TEST 'AUDIBLE AND VISUAL ALARMS. <br /> C 3. ANNUAL INTEGRITY TEST(0.1 GPH) J�_ ❑2. MON7 HLY 4.2 GPH TEST - <br /> ri kfi ❑3. ANNUAL INTEGRITY TFST(D.I OPH) J({71 <br /> CONVENTIONAL SUCTION SYSTEMS ❑4. DAILY VISUAL CHECK 1 <br /> 135. DAILY VISUAL MONITORING OF PUMPING SYSTEM+TRIENNIAL,PIPING CONVENTIONAL,SUCTION SYSTEMS(Chcck all that apply) <br /> INTEGRITYTEST(O.IGPH) ❑S DA)LYVISOALMONITORRJ(iOFPIPINC'.ANDPUNIPINGSYS7EM <br /> SAFE SUCITON SYSTI;IMIS{NO VALVES IN BELOW GROUND PIPING): <br /> ❑7. SELFMONITORING [16, TRIE'NNIALLNTEGRITY 7EST(0.I GVH) <br /> GRAVITY FLOW SAVE SUCTION SYS"MMS(NO VALVES IN BELOW GROUND PIPING); <br /> ❑9. BIANNIAI.1N FrjRll•Y TF.ST(O.1 GPH) ❑7. SELF MONITORING <br /> GRA VITY FLOW{Check all tlial apply): <br /> 09. DAILY VISUAL MONITORING <br /> SECONDARILY CONTAINED PIPING ❑9, BIENNIAL INTEGRITY TEST(D.1 GPH) <br /> PRESSURIZFD PIPING(CIKck ell Ihet apply): SECONDARILY CONTAINED PIPING <br /> PP Y) PRESSURIZED PIPING(Check all that apply): <br /> 10, CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLF AND VISUAL 1D. CONTINUOUS TUR111NE SUMP SENSOR ALARMS AND(Check one) WITH AUDIBLE AND VISUAL, <br /> 0 a_AUTO PUMP SHUT OFF WHEN LEAK OCCURS ALARMS AND(Check one) <br /> Q b.AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM Da. AUTO PUMP SHUT OFF WHEN A LEAK OCCURS <br /> DISCONNECTION ❑h. AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM <br /> (]c. NO AUTO PUMP SHUT OFF DISCONNECTION <br /> ❑ <br /> i. AUTOMATIC LINE LEAK DETECTOR(3.0 GP14 nST)WITHFLAW SFIUT Cc. NO AUTO PUMP 514UT OFF <br /> OFF OR RESTRICTION Q 11. AUTOMAII C LEAK DETECTOR <br /> ❑12. ANNUAL INTEGRITY TEST(0.1 GPI Il <br /> SUCTION/GRAVITY SYSTEM ❑12. ANNUAL]INTEGRITY TEST(0.1 OPF3) <br /> M 13. CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUA L ALARMS SOC7IOWGRAVITY SYSTEM <br /> EIhERGENCY GENERATORS ONLY(Check a31 dud apply) Ell7. CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS <br /> 14. CONTINUOUS SUMP SENSOR WJTIIOIJ AUTO PUMP SHUT OFF EMERGENCY GENERATORS ONLY(Check all dial apply) <br /> AUDIZLE AND VISUAL..ALARMS ❑14.CONTINUOUS SUMP SENSOR AI HT OUT AUTO PUMP SHUT OFF <br /> ❑J5. AUTOMATIC LINE LCAK DETECTOR (3.0 GPIs TEST W1TH AUDIBLE AND VISUAL ALARMS <br /> SHUT OFF OR RESTRICTION } '-DUZ FLOW <br /> ❑IS.AUTOMATIC LINT 1.F.Af{DETECTOR(3,0 GpH TEST} <br /> ANiVUAL INTEGRITY TEST(0.1 GP") <br /> ❑' DAILY VISUAL CHECK ❑16-ANNUAL[NTEGItlTY'1'EST(D.I GPH) <br /> - Q 17,DAILY 4TSIJAI.CHECK <br /> '14�r±MI1�IF�N"L- <br /> DISPENSER CONTAINNI ENT 4n FLOAT MECHANISM THAT SHUTS SHEVALVE .s l <br /> DATE INSTALLED Q2. CONTINUOUS DISPENSER PANSfNOFOFF F TEAR SHEAR <br /> ANDVFSUALAI.AR1�iS 4 DAILYViSUALCHECK 469 <br /> 1:13. CONTINUOUS DISPENSER PAN "SOR ATH AUTO SHUT OFF FOR ©;� TRENCHlI.WFRMONITORING <br /> DISPLLASER+AUOIBI,EANDVISIJ,tLALARM5 Q6, NONF <br /> Lt.;CJrw'h EQJc7PEtt1 :. .., <br /> 1 tertity the intarmadotl provided herein is true and accurate to the best of my knoWIedW, <br /> 91GNA 1 E CIF OWNEWUP R I' - .. <br /> DATE <br /> NAMF,OFOWN QPERATO { t) �O 47D <br /> �1'�Q TITI.FOFOV6 RIPERATOR 472 <br /> Permit Numher(Agency use only) 47+ Permit AppTaVed By(Agency ux ani <br /> Y) 474 1 Permit Expiration Mare(Agency use only) 475. <br /> UP('F hwfivrc-h(1/99).314 http:/Jwwvr.urlitiD rs org <br /> Rev,02/1(010 <br /> Xi�� iJrdASH-1 dH WdBT :C 900a Ta .idd <br />