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r I D PROGRAM CONSOLIDATED FOR* TANKS UNDERGROUND STORAGE TANKS - TANK PAGE 2 VL PIPING CONSTRUCTION(Check ell that apply) Page 6 of 10 UNDERGROUND PIPING ABOVEGROUND PIPING SYSTEM TYPE VI.PRESSURE ❑ 2.SUCTION ❑3.GRAVITY 458 ❑ 1.PRESSURE ❑ 2.SUCTION ❑ 3.GRAVITY 459 CONSTRUCTION rEl 11.SINGLE WALL ❑3.LINED TRENCH 1199.OTHER 460 ❑ 1.SINGLE WALL 1195.UNKNOWN 462 MANUFACTURER DOUBLE WALL 1:195.UNKNOWN 46t El 2.DOUBLE WALL 1:199.OTHER MANUFACTURER 463 ❑ 1.BARE STEEL ❑ 6.FRP COMPATIBLE w/IN%METHANOL ❑ 1.BARE STEEL 116.FRP COMPATIBLE a,/IN%METHANOL ❑2.STAINLESS STEE ❑ 7.GALVANIZED STEEL ❑2.STAINLESS STEE 1:17.GALVANIZED STEEL ❑, PLASTIC COMPATIBLE W/CONTENTS El 95.UNKNOWN El PLASTIC COMPATIBLE W/CONTENTS El 95.UNKNOWN 3 4PL.FIBERGLASS ❑ 8.FLEXIBLE(HDPE) ❑ 99.OTHER ❑4.FIBERGLASS ❑ 8.FLEXIBLE(HDPE) 1-199.OTHER ❑ 5.STEEL W/COATING ❑ 9.CATHODIC PROTECTION 464 ❑ 5.STEEL W/COATING ❑ 9.CATHODIC PROTECTION 465 VII.PIPING LEAK DETECTION(Check all that apply)(A description ofthe monBoring pagrmn shell be attached to the tical agency.) UNDERGROUND PIPING ABOVEGROUND PIPING SINGLE WALL PIPING 466 SINGLE WALL PIPING 467 PRESSURIZED PIPING(Check all that apply): PRESSURIZED PIPING(Check all that call ❑ 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 ❑ El 3.ANNUAL INTEGRITY TEST(0.1 GPH) 2.MONTHLY 0.2 GPH TEST El3.ANNUAL INTEGRITY TEST(0.1 GPH) ❑ 4.DAILY VISUAL CHECK CONVENTIONAL SUCTION SYSTEMS CONVENTIONAL SUCTION SYSTEMS(Check all that apply) [15.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): El 7.SELF MONITORING SAFE SUCTION SYSTEMS(NO VALUES IN BELOW GROUNDPIPING): GRAVITY FLOW ❑ 7.SELF MONITORING ❑ 9.BIENNIAL INTEGRITY TEST(0.1)GPH GRAVITY FLOW(Chock ell that apply): ❑ 8.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 ANT�"(Check one) ALARMS AND(Check one) 0/a.jrt')T/ O PUMP SHUT OFF WHEN A LEAK OCCURS ❑a.AUTO PUMP SHUT OFF WHEN A LEAK OCCURS 1,.-1,W/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 1.AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)WITH El 11.AUTOMATIC LEAK DETECTOR FLOW SHUT OFF OR 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(Check eft that mply) EMERGENCY GENERATORS ONLY(Check all that epply) ❑ 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 VIII.DISPENSER CONTAINMENT DISPENSER CONTAINMENT ❑ 1.FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE ❑4.DAILY VISUAL CHECK DATE INSTALLED 468 ❑2.CONTINUOUS DISPENSER PAN SENSOR+AUDIBLE AND VISUAL ALARMS El5.TRENCH LINER/MONITORING Q-S.0CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR ❑ 6.NONE DISPENSER+AUDIBLE AND VISUAL ALARMS 469 IX.OWNER/OPERATOR SIGNATURE 1 terrify that the inforaation vided herein u true and accurate to the best art,knoale l e. SIGNATURE OF OWNER/OPERATOR DATE 470 NAME OF OWNER/OPERATOR(print) TITLE OF OWNER/OPERATOR 471 4]2 Pemdt Number(For local use only) 473 Perm Approved(For local one only) 474 Peadt Expiration Date(For local use only) 475 EE0002768 12/31/200 UPCF(12/99 revised)