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IN 91 IFIED PROGRAM CONSOLIDATED FOI� /,'Z� ! TANK: 'I'A016OW4 Nury PR#: PR02316M FAC#: FA0000957 UNDERGROUND STORAGE TANKS -TANK PAGE 2 l('L( VI.PIPING CONSTRUCTION(Chak a&a.mly) N,3.1`7 UNDERGROUND PIPING ABOVEGROUND PIPING SYSTEM TYPE ® I.PRESSURE ❑ 2.SUCTION ❑ 3.GRAVITY 459 ❑ 1.PRESSURE ❑ 2.SUCTION ❑3.GRAVITY 459 CONSTRUCTION ❑1.SINGLE WALL ❑3.LINED TRENCH ❑ 99.OTHER 460 ❑ 1,SINGLE WALL [195 UNKNOWN 462 ®2 DOUBLE WALL [__195.UNKNOWN ❑ 2.DOUBLE WALL ❑ 99.OTHER MANUFACTURER A O SMITH 46l MANUFACTURER 463 ❑ I.BARE STEEL ❑ 6.FRP COMPATIBLE w/109.METHANOL ❑ L BARE STEEL ❑6.FRP COMPATIBLE w/loo.METHANOL ❑ 2.STAINLESS STEEL ❑ 7.GALVANIZED STEEL [12.STAINLESS STEEL ❑ 7.GALVANIZED STEEL ❑ PLASTIC COMPATIBLE W/CONTENTS ❑ 95.UNKNOWN ❑ PLASTIC COMPATIBLE W/CONTENTS ❑ 95.UNKNOWN ® 4.FIBERGLASS ❑ 8.PLEXIBLE(HDPE) ❑ W OTHER ❑ 4.FIBERGLASS ❑ 8.FLEXIBLE(HDPE) ❑99.OTHER ❑ 5.STEEL W/COATING ❑ 9.CATHODIC PROTECTION 464 ❑ 5.STEEL W/COATING ❑ 9.CATHODIC PROTECTION 465 VII.PIPING LEAK DETECTION(Ch all:hneppN)(Aa Itxadit i-mllp:o "l m.ubminedwnrc low a8e y.) UNDERGROUND PIPING ABOVEGROUND PIPING SINGLE WALL PIPING 466 SINGLE WALL PIPING 467 PRESSURIZED PIPING(Cheek all that apply): PRESSURIZED PIPING(Cheek all that apply): ❑ I.ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP SHUT OFF ❑ L 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 VISUALALARMS. VISUAL ALARMS. ❑ 2.MONTHLY 0.2 GPH TEST ❑ 2.MONTHLY 0.2 GPH TEST ❑ 3.ANNUAL INTEGRITY TEST(0.1 GPH) ❑ 3.ANNUAL INTEGRITY TEST(0 1 GPH) ❑4.DAILY VISUAL CHECK CONVENTIONAL SUCTION SYSTEMS CONVENTIONAL SUCTION SYSTEMS(Check all that apply) ❑ 5.DAILY VISUAL MONITORING OF PUMPING SYSTEM+TRIENNIEAL 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(Cheek all that apply): ❑ 8.DAILY VISUAL MONITORING ❑ 9.BIENNL3L 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 AN D VISUAL 10,CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL ALARMS AND(Chak ma) ALARMS AND(Chale mn) ® a.AUTO PUMP SHUT OFF WHEN A LEAK OCCURS ❑ %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 ❑c. NO AUTO PUMP SHUT OFF ❑ c. NO AUTO PUMP SHUT OFF ® 11.AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)WITH FLOW SHUT OFF OR ❑ I I AUTOMATIC LEAK DETECTOR RESTRICTION ❑ 12.ANNUAL INTEGRITY TEST(0.1 GPH) ❑ 12.ANNUAL INTEGRITY TEST(0.1 GPH) SUCTION/GRAVITY SYSTEM SUCTION/GRAVITY SYSTEM ❑ 13.CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS ❑ 13.CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS EMERGENCY GENERATORS ONLY(Chale ae:hat apply) EMERGENCY GENERATORS ONLY(Chak all mn appy) ❑ 14.CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF" ❑ 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 ❑ 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 VUL DISPENSER CONTAINMENT DISPENSER CONTAINMENT ❑ I.FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE ❑4.DAILY VISUAL CHECK DATE INSTALLED yba ® 2 CONTINUOUS DISPENSER PAN SENSOR+AUDIBLE AND VISUAL ALARMS ❑ 5.TRENCH LINER/MONITORING ❑ 3.CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR ❑ 6.NONE DISPENSER,AUDIBLE AND VISUAL ALARMS 465 DL OWNER/OPERATOR SIGNATURE 1a fymn iafmmM.'rmftJ lamem 1.nM�w to batormYka Iw" SIGNATURE OF OWNER/OPERATOR DATE 470 FN ?OFOWNER/OPERATOR Mt TITLE OFSI ER/OPERATOR °71 PRESIDENT 4number lFm 1a wo*) 473 PermitApp (Fa 10a manly) 474 Pmail Expimlioa Duc(Fa lard ua oay) 475 T0004281 EE0000646 12/31/1993 12_•OO:OOAM UPCF(12/99 revised)