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nol UNIFIED PROGRAM CONSOLIDATED FORM fzlv2� TANKS woq UNDERGROUND STORAGE TANKS -TANK PAGE 2 p Pae of VI.PI1'ING:CONSTRUCTION Cn.&..ii mai UNDERGROUND PIPING ABOVEGROUND PIPING SYSTEM TYPE ❑I.PRESSURE .SUCTION 0 3.GRAVITY 49. CO]1,PRESSURE 0 2.SUCTION MANUFACTURER J0aSINGLE WALL 0 3.LINED TRENCH ❑99.OTHER 460. 0'L SINGLE WALL U 3 GRAVITY 452. CONSTRU ION/ ❑2.DOUBLE WALL I, ❑95.UNKNOWN 46x. ❑95.UNKNOWN ❑2.DOUBLE WALL N ' -/ ❑99.OTHER MANUFACTURER BARE STEEL 461. MANUFACTURER 163. D 6.FRP COMPATIBLE W/100%METHANOL 0 1.BARE STEEL 0 2.STAINLESS STEEL [17.GALVANIZED STEEL [16.FRP COMPATIBLE W/100%METHANOL ❑2.STAINLESS STEEL ��/Q ❑7.GALVANIZED STEEL 0 3.PLASTIC COMPATIBLE WITH CONTENTS D 95.UNKNOWN D 3.PLASTIC COMPATIBLE/TENTS 0 S.FLEXIBLEHDPE D 4.FIBERGLASS 0 8,FLEXIBLE(HDPE) D 99.OTHER ( ) D 99.OTHER ❑4.FIBERGLASS 0 9.CATHODIC PROTECTION ❑5.STEEL W/COATING ❑9 CATHODIC PROTECTION 464. 1-15,STEEL W/COATING ❑95 UNKNOWN 165. -VILPII'WGliEA PIPING TION cnc<k.RiM1si I .A.dcsni nonohhe moniiohull r.,hall,`c.i.auirm.to }l mc, - UNDERGROUNTD PIPING ABOVEGROUND PIPING SINGLE WALL PIPING ��6 / 1Q� 466. SINGLE WALL PIPING PRESSURIZED PIPING(Check all that apply): 467. PF y)° PRESSURIZED PIPING(Check all that apply): C3 I. ELECTRONIC LME LEAK DETECTOR 3.0 GPH TEST WITH AMO PUMP. D 1. ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST W SHUT-OFF FOR LEAK,SYSTEM FAILURE,AND SYSTEM DISCONNECTION SHUTOFF FOR L WITH AUTO PUMP +AUDIBLE AND VISUAL ALARMS. +AUDIBLE AR E LEAK AL FS. ALURE,AND SYSTEM DISCONNECTION 02. MONTHLY 0.2 GPH TEST 02. MONTHLY 0.2 GPH TEST 03. ANNUAL INTEGRITY TEST(0.1 GPH) 133 ANNUAL INTEGRITY TEST(0.1 GPH) 04. DAILY VISUAL CHECK CONVENTIONAL SUCTION SYSTEMS CONVENTIONAL SUCTION SYSTEMS(Check all that I 0 5. DAILY VISUAL MONITORING OF PUMPING SYSTEM+TRIENNIAL PIPING PP y) INTEGRITY TEST(0.1 GPH) 05. DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): 116, TRIENNIAL INTEGRITY TEST(0.1 GPH) [17. SELF MONITORING SAFE SUCTION SYSTEMS NO VALVES IN BELOW GROUND PIPING): GRAVITY FLOW / 07. SELF MONITORING 09- BIENNIAL INTEGRITY TEST(0.1 GPH) f GRAVITY FLOW(Check all that apply): V ❑8. DAILY VISUAL MONITORING G/ l 09. BIENNIAL INTEGRITY TEST(0.1 GPH) SECONDARILY CONTAINED PIPING f:� / SECONDARILY CONTAINED PIPING PRESSURIZED PIPING(Check all that apply): PRESSURIZED PIPING(Check all that apply): I0. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL 10. CONTINUOUS TURBINE SUMP SENSOR W ALARMS AND(Check one) ALARMS AND(Check one) WITH AUDIBLE AND VISUAL ❑a AUTO PUMP SHUT OFF WHEN A LEAK OCCURS D it. AUTO PUMP SHUT OFF WHEN A LEAK OCCURS ❑It.AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM DISCONNECTION 0 b.AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM Cc. NO AUTO PUMP SHUT OFF DISCONNECTIONCc, NO AUTO PUMP SHUT OFF ❑11. AUTOMATTST)WITH FLOW SHUT C LINE LEAK DETECTOR(3.0 GPH TE OFF OR RESTRICTION D 11.AUTOMATIC LEAK DETECTOR ❑12. ANNUAL INTEGRITY TEST(0.I GPH) D 12.ANNUAL INTEGRITY TEST(0.1 GPH) SUCTION/GRAVITY SYSTEM SUCTION/GRAVIT-S'SYSTEM El 13. CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS 013.CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS EMERGENCY GENERATORS ONLY(Check all that apply) EMERGENCY GENERATORS ONLY(Check all that apply) 0 14. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF. 0 14. CONTINUOUS SUMP SENSOR AUDIBLE AND VISUAL ALARMS WITH�O IT_AUTO PUMP SHUT OFF 015. AUTOMATIC LINE LEAK DETECTOR (3.0 GPH TEST) WITHOUT FLOW AUDIBLE AND VISUAL ALARMS SHUT OFF OR RESTRICTION C 15. AUTOMATIC LINE LEAK DETECTOR(3.0 OPH TEST) 0 16. ANNUAL INTEGRITY TEST(0.1 GPH) 0 16. ANNUAL INTEGRITY TEST(0.1 GPH) D 17. DAILY VISUAL CHECK 017. DAILY VISUAL CHECK V111.DISPENSER:CONTAINMENT. DISPENSER CONTAINMENT 469. ❑1. FLOAT MECHANISM THAT SI TUTS OFF SHEAR VALVE DATE INSTALLED 1114. DAILY VISUAL CHECK 469. y^ �MsA,q C ❑2. CONTINUOUS DISPENSER PAN SENSOR+AUDIBLE AND VISUAL ALARMS ❑5. TRENCH/LINER MONITORING /l ad ��/` D 3 DIOSPE SERI+SAUD BLESER PAN AND VISUAL ALARM AUTO SHUT OFF FOR 0 6. NONE �tdP• ' TOR'slGtyq�(tRI " 1 certify that the information provide erein is true end cc�tothct my knowledge. SIGNATURE OF OWNER/OPERATO DATE: 470, NAME OF:OWNER/OPERATOR(print): TITLE OF OWNER/OPERATOR: / _ �f� .y� 472. Perntit Number(Agency use only) 0� ^"ct/ 44 ( 8 Y y) 4A, Permit Approved By(Agency use only) 474. 1 Permit Expiration Date(Agency use only) 475. UPCF hwfwrc-b(1/99)-3/4 htip://www.unidocs.org Rev.02/16/00