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0NIFIED PROGRAM CONSOLIDATED FOR Com` f B TANK: TA016(HH15 a.A PR N: PRO231600 ��N_ j � FAC#: FA0000957 UNDERGROUND STORAGE TANKS -TANK PAGE �/1V VI.PIPING CONSTRUCTION(Check all that apph) Page 5 of 7 UNDERGROUND PIPING ABOVEGROUND PIPING SYSTEM TYPE ® I PRESSURE ❑ 2.SUCTION ® 3 GRAVITY 4'8 ❑ I-PRESSURE ❑ 2.SUCTION ❑ 3.GRAVITY 439 CONSTRUCTION ❑1.SINGLE WALL ❑3.LINED TRENCH ❑ 99.OTHER 460 ❑ 1.SINGLE WALL ❑ 95.UNKNOWN 462 ©2.DOUBLE WALL F-1 95.UNKNOWN El2.DOUBLE WALL ❑ 99.OTHER 463 MANUFACTURER A Q SMITH 45I MANUFACTURER © I BARE STEEL ❑ 6.FRP COMPATIBLE w1 IW/METHANOL ❑ I BARE STEEL ❑ 6.FRP COMPATIBLE%1100%METHANOL ❑ 2.STAINLESS STEEL ❑ 7.GALVANIZED STEEL [] 2.STAINLESS STEEL ❑ 7.GALVANIZED STEEL ❑ PLASTIC COMPATIBLE W/CONTENTS ❑ 95.UNKNOWN ❑ PLASTIC COMPATIBLE W/CONTENTS ❑ 45,UNKNOWN ® 4.FIBERGLASS ❑ S.FLEXIBLE(HDPE) ❑ 99.OTHER ❑ 4.FIBERGLASS ❑ 8.FLEXIBLE(HDPE) ❑ 99.OTHER ❑ 5.STEEL WICOATING ❑ 9,CATHODIC PROTECTION 464 ❑ 5.STEEL W/COATING ❑ 9 CATHODIC PROTECTION 46+ VIL PIPING LEAK DETECTION(Chuck all that apph')(A description of the monitoring program shall be submitted to the local agrnc ) UNDERGROUND PIPING ABOVEGROUND PIPING SINGLE WALL PIPING 466 SINGLE WALL PIPING 467 PRESSURIZED PIPING(Check all that apply): PRESSURIZED PIPING(Check all that apply): '❑ 1.ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP SHUT OFF ❑ I 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) ❑ 3.ANNUAL INTEGRITY TEST(0.1 GPH) ❑ 4.DAILY VISUAL CHECK CONVENTIONAL SUCTION SYSTEMS(Check all that apply) CONVENTIONAL SUCTION SYSTEMS ❑ 5.DALLY VISUAL MONITORING OF PUMPING SYSTEM+TRIENNIEAL PIPING ❑ 5DAILY 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): ❑ S.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(Chesk one) ALARMS AND(Check one) a.AUTO PUMP SHUT OFF WHEN A LEAK OCCURS ❑ a.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 ❑ 11.AUTOMATIC LEAK DETECTOR RESTRICTION ❑ 12 ANNUAL INTEGRITY TEST(0.1 GPH) ❑ 12,ANNUAL INTEGRITY TEST(0.1 GPH) SUCTION/GRAVITY SYSTEM SUCI`IONIGRAVITY SYSTEM ❑ 13.CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS ❑ 13.CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS EMERGENCY GENERATORS ONLY(Check all that apply) EMERGENCY GENERATORS ONLY(Check all that apply) ❑ 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 I5.AUTOMATIC LINE LEAK DETECTOR(3.0 OPH 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 VIII.DISPENSER CONTAINMENT DISPENSER CONTAINMENT ❑ I 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 ❑ 3.CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR [� 6.NONE DISPENSER+AUDIBLE AND VISUAL ALARMS a69 Lei.OWNER/OPERATOR SIGNATURE I=ufy that the information pronided herein is tnre and accurate to the best of my knowledge. _ SIGNATURE OF OWNERlOPFRATOR DATE 470 N OF OWNER/OPERATOR(print) TITLE OF OWNEWOPERATOR z L '- r� to 471 PRESIDENT 47z I'rmut Number 1 For kcal use onlc) 473 Permit Apprcncd(For local use only) 474 Permit Expiration Date(For local use only) 475 PT0004281 EE00006446 12/31/1993 12:00:OOAM UPCF(12199 revised)