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IFIED PROGRAM CONSOLIDATED FOR* r� � 1 TANK: PR0231600 PR#: PR0231SOII FAC#: FAO(N10957 UNDERGROUND STORAGE TANKS - TANK PAGE 2 VI.PIPING CONSTRUCTION(Chwk all that appl)) Paye 7 of 7 UNDERGROUND PIPING ABOVEGROUND PIPING SYSTEM TYPE ® 1 PRESSURE ❑ 2.SUCTION ❑ 3.GRAVITY 438 ❑ 1 PRESSURE ❑ 2 SUCTION ❑ 3 GRAVITY 459 CONSTRUCTION [:]I SINGLE WALL ❑3.LINED TRENCH ❑ 99.OTHER 460 ❑ I.SINGLE WALL ❑ 95.UNKNOWN 462 Q 2 DOUBLE WALL ❑95-UNKNOWN ❑ 2.DOUBLE WALL ❑ 99,OTHER 463 MANUFACTURER A 0 SMITH 461 MANUFACTURER ❑ 1.BARE STEEL ❑ 6.FRP COMPATIBLE Nv!Ina%METHANOL ❑ L BARE STEEL ❑ 6.FRP COMPATIBLE x1 tOnYo METHANOL ❑ 2.STAINLESS STEEL ❑ 7.GALVANIZED STEEL ❑ 2.STAINLESS STEEL ❑ 7.GALVANIZED STEEL ❑ PLASTIC COMPATIBLEW/CONTENTS ❑ 95.UNKNOWN [] PLASTIC COMPATIBLE WI CONTENTS ❑ 95.UNKNOWN 4.FIBERGLASS ❑ 8.FLEXIBLE(HDPE) ❑ 99.OTHER ❑4-FIBERGLASS ❑ 8 FLEXIBLE(HDPE) ❑ 99.OTHER ❑ 5.STEEL WICOATING ❑9.CATHODIC PROTECTION 464 ❑ 5.STEEL WICOATING ❑9 CATHODIC PROTECTION 465 VII.PIPING LEAK DETECTION(Chak all that apply)(A description of the monitoring prog m shall be submitted to the local agenm) UNDERGROUND PIPING ABOVEGROUND PIPING SINGLE WALL PIPING 4f,6 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 ❑ 1.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 I GPH) © 3 ANNUAL INTEGRITY TEST(0.1 GPH) ❑ A.DAILY VISUAL CHECK CONVENTIONAL SUCTION SYSTEMS(Check all that appiy) CONVENTIONAL SUCTION SYSTEMS 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 GROUNIIPIPING): SAFE SUCTION SYSTEMS(NO VALUES IN BELOW GROUNDPIPING): ❑ 7.SELF MONITORING ❑ 7.SELF MONITORING GRAVITY FLOW ❑ 9GRAVITY FLOW(Check all that apply): .BIENNIAL INTEGRITY TEST(0.1)GPH ❑ S.DAILY VISUAL MONITORING ❑ 9.BIENNIAL INTEGRITY TEST(0.1)GPH SECONDARILY CONTAINED PIPFNG SECONDARILY CONTAINED PIPING PRESSURIZED PIPING(Check all that apply): PRESSURIZED PIPING(Check all that apply): I0.CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL 10.CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL ALARMS AND(Chink tmc) ALARMS AND(Check erre) ® 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.D 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) SUCTIONIGRAVTTY SYSTEM SUCTIONIGRAVITY 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 i 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 VIIL DISPENSER CONTAINMENT DISPENSER CONTAINMENT ❑ 1.FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE ❑4-DAILY VISUAL CHECK DATE INSTALLED 469 [XI 2.CONTINUOUS DISPENSER PAN SENSOR+AUDIBLE AND VISUAL ALARMS ❑ S.TRENCH LINER/MONITORING ❑ 3.CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR ❑ 6,NONE DISPENSER+AUDIBLE AND VISUAL ALARMS a69 DL OWNERIOPERATOR SIGNATURE I certify that the information prmidod herein is true and actuate to the best of my knmiecig. SIGNATURE OF OWNFWOPERATOR DATE 470 NA Vr nF OyWtNER(OPEtRATOR( 'nt) ��/►` 471 TITLE OF OWNER/OPERATOR 475 PRESIDENT F,1umber(For localuse only) 473Permit Apprmxd(For local use onlN) 474 Permit E,%pirmion Date(For localuse only) 47S T0004281 EE0000646 12/31/1993 12:00:OOAM UPCF(12/99 revised)