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UNIFIED PROGRAM CONSOLIDATED FORM TANKS UNDERGROUND STORAGE TANKS - TANK PAGE 2 kQ _ - - '4L PIITING:.CONSTRUGTION Chetk,I;iAi - Pae of UNDERGROUND PIPING ABOVEGROUND PIPING SYSTEM TYPE ❑11.PRESSURE .SUCTION 0 3.GRAVITY 458. 0 1.PRESSURE 0 2.SUCTION MANUFACTURER 0""SINGLE WALL ❑3.LINED TRENCH ❑99.OTHER 460. ❑'1.SINGLE WALL U 3 GRAVl7l' 459. 0 2.DOUBLE WALL 0 95.UNKNOWN 195'UNKNOWN 46f. MANUFACTURER ❑2.DOUBLE WALL/v ❑99.OTHER 461. MANUFACTURER BARE STEEL 0:6.FRP COMPATIBLE W/100%METHANOL 0 1.BARE STEEL 461, 0 2.STAINLESS STEEL 0 7,GALVANIZED STEEL 0 6.FRP COMPATIBLE W/100%METHANOL ❑2.STAINLESS STEEL "�,,{,// 0 7.GALVANIZED STEEL 0 3.PLASTIC COMPATIBLE WITH CONTENTS ❑95.UNKNOWN 0 3.PLASTIC COMPATIBLE W/CONTENTS 0 8.FLEXIBLE(HDPE) C199.OTHER ❑4.FIBERGLASS ❑S.FLEXIBLE(HDPE) 0 99.OTHER 0 4.FIBERGLASS 0 9.CATHODIC PROTECTION 0 5.STEEL W/COATING ❑9.CATHODIC PROTECTION 464. 0 5 STEEL W/COATING ❑95.UNKNOWN 465, YII.PTPING.LEAK DETECTION enak dSAu I Adeuriiion of�hevroaitone rvm ehill.6asubmmWro iM1 kyle enc,-. ' UNDERGROUND PIPING re ABOVEGROUND PIPING SINGLE WALL PIPING .S41e T-10,,) 466 SINGLE WALL PIPING PRESSURIZED PIPING(Check all that apply): 467. PF y)0 PRESSURIZED PIPING(Check all That apply): 01. ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST MM AUTO PUMP. 01. ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST W SHUT-OFF FOR LEAK,SYSTEM FAILURE,AND SYSTEM DISCONNECTION SHUTOFF FOR LEAK,SYSTEM FAILURE,AND SYSTEM D DISCONAUTO NECTION +AUDIBLE AND VISUAL ALARMS. +AUDIBLE AND VISUAL ALARMS. 02. MONTHLY 0,2 GPH TEST 0 2. MONTHLY 0.2 GPH TEST ❑3. ANNUAL INTEGRITY TEST(0.1 GPH) 03. ANNUAL INTEGRITY TEST(0.1 GPH) 04. DAILY VISUALCHECK CONVENTIONAL SUCTION SYSTEMS CONVENTIONAL SUCTION SYSTEMS(Check all that e I 05. DAILY VISUAL MONITORING OF PUMPING SYSTEM+TRIENNIAL PIPING PP y) INTEGRITY TEST(0.1 GPH) (35. DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM SAFE SUCTION SYSTEMS(NO VALVES IN BELO W GROUND PIPING): 0 C TRIENNIAL INTEGRITY TEST(0.1 GPH) 07. SELF MONITORING SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): GRAVITY FLAW / 07. SELF MONITORING 0 9. BIENNIAL INTEGRITY TEST(0.1 GPH) f GRAVITY FLOW(Check all that apply): 0 8. DAILY VISUAL MONITORING Tp L"C/ 1 09. BIENNIAL INTEGRITY TEST(0.I 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 ore) ALARMS AND(Check one) 0 a. AUTO PUMP SHUT OFF WHEN A LEAK OCCURS 0 a. AUTO PUMP SHUT OFF WHEN A LEAK OCCURS ❑b.AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM 0 b.AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM NO AUTO PUMPN DISCONNECTION 0c. NO TIC L PUMP SHUT OFF 0e. NO AUTO PUMP SHUT'OFF ❑I1. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)WITH FLOW SHUT OFF OR RESTRICTION ❑11.AUTOMATIC LEAK DETECTOR 0 12. ANNUAL INTEGRITY TEST(0.1 GPH) D 12. ANNUAL INTEGRITY TEST(0.1 GPH) SUCTION/GRAVITY SYSTEM SUCTION/GRAVITY SYSTEM 013. CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS 013. CONTINUOUS SUMP SENSOR+AUDIBLEAND VISUAL ALARMS EMERGENCY GENERATORS ONLY(Check all Out apply) EMERGENCY GENERATORS ONLY(Check all that apply) [114. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUTOFF. 0 14.CONTINUOUS SUMP SENSOR T P AUDIBLE AND VISUAL ALARMS AUDIBLE AND VISUAL ALARMS AUTO PUMP SHUT OFF 015. AUTOMATIC LINE LEAK DETECTOR (3.0 GPH TEST) WITHOU FLOW SHUT OFF OR RESTRICTION 1-115. AUTOMATIC LINE LEAK DETECTOR(3.0 OPH TEST) (j 16. ANNUAL INTEGRITY TEST Is.I GPH) 0 16. ANNUAL INTEGRITY TEST(0.I GPH) 017. DAILY VISUAL CHECK 017. DAILYVISUALCt CK VI1L:zTtNS>R�ONIAIS�iut DISPENSER CONTAINMENT 47E32. AT MECHANISM THAT SHUTS OFF SHEAR VALVE DATE METALLED E14. DAILY VISUAL CHECK 469. I5NS ) TINUOUS DISPENSER PAN SENSOR+AUDIBLE AND VISUAL ALARMS 05. TRENCH/LINER MONITORING DIII T CONTINUOUS DIS LE AND IENSER N SE SORMg E AUTO SHUT OFF FOR 06. NONE -hC,OWNEWOPERATOR SIGNATURk' - 1 certify that the information provid rein is[rue d a ate to the cst of my knowledge. SIGNATURE OF OWNER/OPERATO DATE: 19 no. NAME OF OWNER/OPERATOR(prinI), �f er �� TITLEOFOWNER/OPERATOR: / _ ni. Permit Number(Agency use only) I 471 1 Pencil Appmved By(Agency use only) 474. 1 Pemut Expiration Date(Agency use only) 475. UPCF hwfwrc-b(09).3/4 http://"w.unidocs.org Rev.02/16/00