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' USED PROGRAM CONSOLIDATED FOR* TANKS UNDERGROUND STORAGE TANKS - TANK PAGE 2 VI.PIPING CONSTRUCTION(cheek it that apply) Page 9 of 10 UNDERGROUND PIPING ABOVEGROUND PIPING SYSTEM TYPE Url.PRESSURE ❑ 2.SUCTION ❑ 3.GRAVITY 458 ❑ I.PRESSURE ❑ 2.SUCTION ❑3.GRAVITY 459 CONSTRUCTION ❑2,SINGLE WALL ❑ 3.LINED TRENCH ❑ 99.OTHER 460 ❑ 1.SINGLE WALL ❑95.UNKNOWN 462 DOUBLE WALL ❑ 95.UNKNOWN ❑ 2.DOUBLE WALL ❑99.OTHER MANUFACTURER 461 MANUFACTURER 463 ❑ 1.BARE STEEL ❑ 6.FRP COMPATIBLE w/IOOY.METHANOL ❑ 1.BARE STEEL ❑6.FRP COMPATIBLE w/10 METHANOL ❑2.STAINLESS STEE [17.GALVANIZED STEEL El 2.STAINLESS STEE El 7.GALVANIZED STEEL ❑P>,wasst,COMPATIBLE W/CONTENTS E] 95.UNKNOWN ❑ PLASTIC COMPATIBLE W/CONTENTS El 95.UNKNOWN 4.FIBERGLASS ❑ 8.FLEXIBLE(HDPE) ❑ 99.OTHER ❑ 4.FIBERGLASS 1:18.FLEXIBLE(HDPE) 1199.OTHER ❑ S.STEEL W/COATING ❑9.CATHODIC PROTECTION 464 ❑ 5.STEEL W/COATING ❑9.CATHODIC PROTECTION 46s VII.PIPING LEAK DETECTION(Check a0 that apply)(A description ofthe monitoring program shell be submined to the local agmry) UNDERGROUND PIPING ABOVEGROUND PIPING SINGLE WALL PIPING 466 SINGLE WALL PIPING 46] PRESSURIZED PIPING(Check all that apply): PRESSURIZED PIPING(Check 0 ❑ that appy):1.ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP El1.ELECTRONIC LINE LEAK DEFECTOR 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 ❑ 2.MONTHLY 0.2 GPH TEST ❑ 3.ANNUAL INTEGRITY TEST(0.1 GPH) ❑ 3.ANNUAL INTEGRITY TEST(0.1 GPH) [14.DAILY VISUAL CHECK CONVENTIONAL SUCTION SYSTEMS CONVENTIONAL SUCTION SYSTEMS(Check all that apply) [15.DAILY VISUAL MONITORING OF PUMPING SYSTEM+TRTENMEAL ❑ S.DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM PIPING INTEGRITY TEST(0.1 GPH) ❑ 6.TRIENNIAL INTEGRITY TEST(0.1 GPM, SAFE SUCTION SYSTEMS(NO VALUES IN BELOW GROUNDPIPING): SAFE SUCTION SYSTEMS(NO VALUES IN BELOW GROUNDPIPING): [17.SELF MONITORING ❑ 7.SELF MONITORING GRAVITY FLOW [-19.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 ell that apply): 10.CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL 10.CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL ALARMS AND(Chock one) ALARMS AND(Chock one) LILC Al O PUMP SHUTOFF WHEN A LEAK OCCURS ❑ a.AUTO PUMP SHUT OFF WHEN A LEAK OCCURS ,4-r,W. AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND ❑It.AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM DISCONNECTION SYSTEM DISCONNECTION NO AUTO PUMP SHUT OFF ❑ c. NO AUTO PUMP SHUT OFF 1.AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)WITH FLOW SHUT OFF OR RESTRICTION El11.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(Check all that apply) EMERGENCY GENERATORS ONLY(Check an 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 ❑ 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. OUS DISPENSER PAN SENSOR+AUDIBLE AND VISUAL ALARMS ❑ 5.TRENCH LINER/MONITORING .CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR ❑ 6.NONE DISPENSER+AUDIBLE AND VISUAL ALARMS 469 D{.OWNER/OPERATOR SIGNATURE I cortify that the infomtation providect herein is true and accurate to the best ofinny knowledge. SIGNATURE OF OR'NER/OPERATOR DATE 470 NAME OF OWNER/OPERATOR(print) TITLE OF OWNER/OPERATOR 4]I 4]2 Pemdt Number(For local use only) 473 Permit Approved(For local use only) 474 Pemut Expiration Date(For local use only) 475 EE0002768 12/31/200 UPCF(12/99 revised)