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AMD PROGRAM CONSOLIDATED FOR TANKS UNDERGROUND STORAGE TANKS - TANK PAGE 2 VI.PIPING CONSTRUCTION(check all that apply) Page 3 of IO UNDERGROUND PIPING ABOVEGROUND PIPING SYSTEM TYPE 1.PRESSURE ❑ 2.SUCTION ❑3.GRAVITY 458 ❑ L PRESSURE ❑2.SUCTION ❑ 3.GRAVITY 459 CONSTRUCTION ,❑ 11,SINGLE WALL ❑ 3.LINED TRENCH ❑99.OTHER 460 ❑ 1.SINGLE WALL ❑ 95.UNKNOWN 462 y/2.DOUBLE WALL ❑ 95.UNKNOWN ❑ 2.DOUBLE WALL ❑ 99.OTHER MANUFACTURERam 461 MANUFACTURER 463 ❑ 1.BARE STEEL ❑ 6.FRP COMPATIBLE w/100h&METHANOL ❑ L BARE STEEL ❑6.FRP COMPATIBLE w/1011%METHANOL ❑ 2.STAINLESS STEE ❑ 7.GALVANIZED STEEL ❑ 2.STAINLESS SITE ❑ 7.GALVANIZED STEEL ❑P C COMPATIBLE W/CONTENTS El 95.UNKNOWN El PLASTIC COMPATIBLE W/CONTENTS El 95.UNKNOWN 4.FIBERGLASS ❑ 8.FLEXIBLE(HDPE) ❑ 99.OTHER ❑ 4.FIBERGLASS ❑ S.FLEXIBLE(HDPE) 1199.OTHER ❑ 5.STEEL W/COATING ❑ 9.CATHODIC PROTECTION 464 ❑ 5.STEEL W/COATING ❑ 9.CATHODIC PROTECTION av5 VII.PIPING LEAK DETECTION(Check all that apply)(A doicliption ofthe monitorina be subna td to the tical agency.) UNDERGROUND PI-PING INNG ABOVEGROUND PIPING SINGLE WALL PIPG 466 SINGLE WALL PIPING 467 PRESSURIZED PIPING(Check all that apply): PRESSURIZED PIPING(Chock all that apply): ❑ 1.ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP ❑ 1.ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP SHUT OFF FOR LEAK,SYSTEM FAILURE,AND SYSTEM DISCONNECTION+ SHUT OFF FOR LEAK,SYSTEM FAILURE,AND SYSTEM DISCONNECTION+ AUDIBLE AND VISUAL ALARMS. AUDIBLE AND VISUAL ALARMS. ❑2.MONTHLY 0.2 GPH TEST 3.ANNUAL INTEGRITY TEST(0.1 GPH) El2.MONTHLY 0.2 GPH TEST El 3.3.ANNUAL INTEGRITY TEST(0.1 GP ❑ ❑4.DAILY VISUAL CHECK CONVENTIONAL SUCTION SYSTEMS CONVENTIONAL SUCTION SYSTEMS(Check all that apply) ❑ 5.DAILY VISUAL MONITORING OF PUMPING SYSTEM+TRIENNIEAL ❑ 5.DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM PIPING INTEGRITY TEST(0.1 GPH) ❑ 6.TRIENNIAL INTEGRITY TEST(0.1 GPH) SAFE SUCTION SYSTEMS(NO VALUES IN BELOW GROUNDPIPING): [:3 7.SELF MONITORING SAFE SUCTION SYSTEMS(NO VALUES IN BELOW GROUNDPIPING): GRAVITY FLOW ❑ 7.SELF MONITORING ❑ 9.13MMAAL INTEGRITY TEST(0.1)GPH GRAVITY FLOW(Chock 0 that apply): ❑ 8.DAILY VISUAL MONITORING El 9.BIENNIAL INTEGRITY TEST(0.1)GPH SECONDARILY CONTAINED PIPING SECONDARILY CONTAINED PIPING PRESSURIZED PIPING(Chock all that apply): PRESSURIZED PIPING(Check au that apply): 10.CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL 10.CONTINUOUS TURBINE SUMP SENSORVIH AUDIBLE AND VISUAL ALARMS AND(Chock one) ALARMS AND(Check one) L�Y2 a.. UTO PUMP SHUT OFF WHEN A LEAK OCCURS 1:1a.AUTO PUMP SHUT OFF WHEN A LEAK OCCURS l6 AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND ❑b.AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM DISCONNECTION SYSTEM 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 RESTRICTION 11.AUTOMATIC LEAK DETECTOR ❑ 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(Chock all that apply) EMERGENCY GENERATORS ONLY(Chock all that 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 10.1 GPH) ❑ 16.ANNUAL INTEGRITY TEST(0.1 GPM ❑ 17.DAILY VISUAL CHECK ❑ 17.DAILY VISUAL CHECK VIII.DISPENSER CONTAINMENT DISPENSER CONTAINMENT ❑ FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE ❑4.DAILY VISUAL CHECK DATE INSTALLED 468 Wt,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 469 DL OWNER/OPERATOR SIGNATURE I certify that the mfonrwion provided herein is we and accurate to the best of,knowkd e. SIGNATURE OF OWNER/OPERATORDATE 470 NAME OF OWNER/OPERATOR(print) TITLE OF OWNER/OPERATOR 4]I 4]2 Pemdt Number(Far local we only) 473 Pemdt AMovd(For local use only) 474 Permit Expiration Date(For local.only) 475 EE0002768 12/31/200 UPCF(12/99 revised)