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i 1 UNJMWD PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANKS -TANK PAGE 2 TANKS VI-PI PTNGCONSTRUCTION Chaekallthet UNDERGROUND PIPING Faga_of_ SYSTEM TYPE ),PRESSURE ABOVEGROUND PIPING ❑2.SUCTION ❑3.GRAVITY oll ❑1.PRESSURE ❑2. SUC110N ❑3.GRAVITY 459 CONSTRUCTION 1.SINGLE WALL ❑3.LINED TRENCH ❑99.OTHER 460 ❑1.SINGLE WALL MANUFAC[URER �2.DOUBLEWALL 095.UNKNOWN ❑95.UNKNOWN 462 MANUFACTURER ❑2.DOUBLE WALL ❑99.OTHER 461 MANUFACTURER 463 ❑1.BARE STEEL 6.PEP COMPATIBLE w/100/ MRTBANpL 0 1,BARE STEEL 112.STAINLESS STEEL [17.GALVANIZED STEEL ❑UtOmowa ❑2. STAINLESS STEEL D 6.FRP COMPATIBLE W/1006 h>EIIiANOt ❑3.PLASTIC COMPATIBLE W,CONTENTS ❑7•GALVANIZED STEEL ❑99. Other ❑3. PLASTIC COMPATIBLE W/CONTENTS ❑g•FLEX®LE(HDPE) ❑99. OTHER ❑4.FIBERGLASS ❑S.FLEXIBLE(HDPE) ❑4. FIBERGLASS ❑5.STEEL W/COATING ❑9.CATHODIC PROTECTION 464 119.CATHODIC PROTECTION ❑5. STEEL W/COATING ❑95.UNKNOWN 465 VII•PIPING LEAK DETECTIONChakellthala 1 Ada cddonofdsemonk,, m sfiall he submiltedmAelacel UNDERGROUND PIPING SINGLE WALL PIPING466 SINGLE WALL PIPING 467 ABOVEGROUND PIPING PRESSURIZED PIPING(Checker[[MuappTy): PRESSURIZED PIPING(Chwkall gut apply): 01.ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST MM AUTO PUMP SHELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST OFF FOR LEAK,SYSTEM FAILURE,AND SYSTEM DISCONNECTION SHUT OFF FOR L WITH AUTO PUMP UT ❑1. AUDIBLE AND VISUAL ALARMS. EAK,SY57EM FAILURE,AND SYSTEM DISCONNECTION+ 112.MONTHLY 0.2 GPH TEST AUDIBLE AND VISUAL ALARMS. Ej ❑2. MONTHLY 0.2 GPH TEST 3.ANNUAL,INTEGRITY TEST(O.IGPH) ❑3.ANNUAL INTEGRITY TEST(0.IGPH) El 4. DAILY VISUAL CHECK CONVENTIONAL SUCTION SYSTEMS CONVENTIONAL SUCTION SYSTEMS(Chock all dmtapply) ❑5.DAILY VISUAL MONITORING OF PUMPING SYSTEM+TRIEM4IAL PIPING TNTEGRITYTEST(0.1 GPI) ❑5.DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM SAFE SUCITON SYSTEMS(NO VALUES IN BELOW GROUNDPIPING): ❑6.TRIENNIAL INTEGRITY TEST(0.1 OPH) ❑7.SELF MONITORING SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): GRAVITY FLAW ❑7.SELF MONrrORTNG ❑9.BIENNIAL INTEGRITY TEST(0.1 GPH) GRAVITY FLOW(Chmkall that apply): ❑S. DAILY VISUAL MONITORING ❑9.BIENNIAL INTEGRITY TEST(0.1 OPH) SECONDARILY CONTAINED PIPING SECONDARILY CONTAINED PIPING PRESSURIZED PIPING(Checkall dw pplyk PRESSURIZED PIPING(Chxkall tMt I 10. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL y) ALARMS AND(Chock oro) 10. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL Ka. AUTO PUMP SHUT OFF WHEN A LEAK OCCURS ALARMS AND(Check one) ❑b. AUTO PUMP SHUT OFF FORLEAKS,SYSTEM FAILURE AND SYSTEM 0 a AUTO PUMP SHUT OFF WHEN A LEAK OCCURS DISCONNECTION ❑b AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM Da NO AUTO PUMP SHUT OFF DISCONNECTION Oe NO AUTO PUMP SHUT OFF 11. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)w�(PLOW SHUT OFF OR RESTRICTION ❑11. AUTOMATIC LEAK DETECTOR PA 12. ANNUAL INTEGRITY TEST(0.1 GPH) ❑12, ANNUAL INTEGRITY TEST(0.1 OPH) 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(Check all that apply) . Y GENERATORS ONLY(Cheek all that apply) EMERGENCYC ❑14. CONTINUOUS SUMP SENSOR WITHOU AUTO PUMP SHUT OFF+ ❑14CONTINUOUS SUMP SENSOR AUDIBLE AND VISUAL ALARMS AUTO PUMP SHUT OFF 1-1 is. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEM M FLOW AUDIBLE AND VISUAL SENSOR SHUT OFF OR RESTRICTION ❑15. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST) ❑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 1$,I,FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE DATE INSTALLED 468El4.DAILY VISUAL CHECK ❑2.CONTINUOUS DISPENSER PAN SENSOR+AUDIBLE AND VISUAL ALARMS ❑5.TRENCH LINER/MONITORING ❑3.CONTINUOUS DISPENSER PAN SENSOR WIM AUTO SHUT OFF FOR DISPENSER+AUDIBLE AND VISUAL ALP EMS (]6.NONE 469 IX.OWNER/OPERATOR SIGNATURE locally that Om infmmadon melded Sesein ie Waend acemata to the bestofmy knowkdga SIGN T 0 PERATOR ^ATE / rOR(pmt) /a�ZL A ato NAME FOWNER/(OPR�A'/ 471 TITLE OF,OoWNE E ITOR rd G/ lLfoa� (' clL *4 an Pe.h Number(ForloaimamlY) 473 Permit Approval(For local use oNY) 474 Permit Expiration Date(Por local tee oNy) 4]5 UPCF(12/99 revised) 12 Formerly SWRCB Form B