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� o UNIFIED PROGRAM CONSOLIDATED FORM TANKS UNDERGROUND STORAGE TANKS -TANK PAGE 2 Xt ?ago of V.I.PIPING.CONSTRUCTION Cheek:.n ilia " 1'j UNDERGROUND PIPING ABOVEGROUND PIPING SYSTEM TYPE D 1.PRESSURE .SUCTION 0 3.GRAVITY 458, 0 I.PRESSURE 0 2.SUCTION 0 3.GRAVITY 459. CONSTRUCTION/ 04,SINGLE WALL D 3.LINED TRENCH 0 99.OTHER 460. 01.SINGLE WALL D 95.UNKNOWN 462. MANUFACTURER 0 2 DOUBLE WALL 0 95.UNKNOWN 0 2.DOUBLE WALL A//-'t D 99.OTHER MANUFACTURER 461. MANUFACTURER 461. -VTBARE STEEL 06.FRP COMPATIBLE W1100%METHANOL 01.BARE STEEL �. / 06.FRP COMPATIBLE W/100%METHANOL 0 2,STAINLESS STEEL D 7.GALVANIZED STEEL D 2.STAINLESS STEEL Y✓//'� D 7.GALVANIZED STEEL 0 3.PLASTIC COMPATIBLE WITH CONTENTS D 95.UNKNOWN 0 3.PLASTIC COMPATIBLE W1 CONTENTS 0 8.FLEXIBLE(HDPE) 0 99.OTHER 0 4.FIBERGLASS 0 S.FLEXIBLE(HDPE) 0 99,OTHER 0 4.FIBERGLASS D 9.CATHODIC PROTECTION D 5.STEEL W/COATING 0 9.CATHODIC PROTECTION 464. 0 S.STEEL W/COATING D 95.UNKNOWN 465, VILPIPINGLEAK DETECTION Cheekaltihat Abveri ton o[�hemonnona n nmshahb'6 svamlY dtoN.kkirya enc. UNDERGROUND PIPING ABOVEGROUND PIPING SINGLE WALL PIPING _5Re7-16�j 466. SINGLE WALL PIPING 467. PRESSURIZED PIPING(Check all that apply): PRESSURIZED PIPING(Check all that apply): 0 I. ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP. [11. 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. [12. MONTHLY 0.2 GPH TEST [32. MONTHLY 0.2 GPH TEST 03. ANNUAL INTEGRITY TEST(0.1 GPH) [13. ANNUAL INTEGRITY TEST(0.1 GPH) 04. DAILY VISUAL CHECK CONVENTIONAL SUCTION SYSTEMS CONVENTIONAL SUCTION SYSTEMS(Check all that apply) D 5. DAILY VISUAL MONITORING OF PUMPING SYSTEM+TRIENNIAL PIPING 05. DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM INTEGRITY TEST(0.1 GPH) SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): [36. TRIENNIAL INTEGRITY TEST(0.1 GPH) 07. SELF MONITORING SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): GRAVITY FLOW / D7. SELF MONITORING [39, BIENNIAL INTEGRITY TEST(0.1 GPH) ^ GRAVITY FLOW(Check all that apply): 08. DAILY VISUAL MONITORING T �L0 09. 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 AND(Check one) ALARMS AND(Check one) 0 a. AUTO PUMP SHUT OFF WHEN A LEAK OCCURS 0 a. AUTO PUMP SHUT OFF WHEN A LEAK OCCURS 0 b.AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM 0 b.AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM DISCONNECTION DISCONNECTION Dc. NO AUTO PUMP SHUTOFF Dc. NO AUTO PUMPSHUT OFF 0 11. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)WITH FLOW SHUT D 11 AUTOMATIC LEAK DETECTOR OFF OR RESTRICTION D 12, ANNUAL INTEGRITY TEST(0.1 GPH) 0 12.ANNUAL INTEGRITY TEST(0.1 GPH) SUCTION/GRAVITY SYSTEM SUCTION/GRAVITY SYSTEM 0 13. CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS 0 13, CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS EMERGENCY GENERATORS ONLY(Check all that apply) EMERGENCY GENERATORS ONLY(Check all that apply) 014. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF 0 14. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF AUDIBLE AND VISUAL ALARMS AUDIBLE AND VISUAL ALARMS [115, AUTOMATIC LINE LEAK DETECTOR (3.0 GPH TEST) WITHOUT FLOW 015. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST) SHUT OFF OR RESTRICTION 0 16. ANNUAL INTEGRITY TEST(0.1 GPH) 016. ANNUAL INTEGRITY TEST(0.1 GPH) DI7. DAILY VISUAL CHECK 017, DAILY VISUAL CHECK VTILDISPENSER'CONTAIN,,&I�,'*Tp' - DISPENSER CONTAINMENT 468. D L FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE E14. DAILY VISUAL CHECK 469. DATE INSTALLED 02. CONTINUOUS DISPENSER PAN S ENSOR+AUDIBLE AND VISUAL ALARMS 05, TRENCH/LINERMONITORING 03. 3 USDISPENSER AND UAL ALARMS OR WITH AUTO SHUT OFF FOR 0 6. NONE DISPENSER A _ . ._ . .._ LY.OWNER/OPERATOR SIGNATURE I certify that the information provided herein is We and ac urate to the best of my knowledge. SIGNATURE OFOWNER/OPEAAT DATE: 470. r. NAME OF OWNERIOPERATOR(print): / TITLE OF OWNER/OPERATOR: �J�a_ /J y, 471. > C Permit Number(Agency use only) 471. Permit Approved By(Agency use only) 474. 1 Permit Expiration Date(Agency use only) 475. UPCF hwfwre-b(1/99)-3/4 http://www.unidGcs.org Rev.02/16/00