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UNIFIED PROGRAM CONSOLIDATED FORM TANKS UNDERGROUND STORAGE TANKS -TANK PAGE 2 Pae of .✓ VL PIPING CONSTRUCTION(Chockalithetyply) UNDERGROUND PIPING ABOVEGROUND PIPING SYSTEM TYPE D 1.PRESSURE 2.SUCTION [13.GRAVITY 459. D 1.PRESSURE [12.SUCTION (:13.GRAVITY 459. CONSTRUCTION/ D 1.SINGLE WALL D 3.LINED TRENCH [199.OTHER 460. ❑L SINGLE WALL D 95.UNKNOWN 462. MANUFACTURER ❑2.DOUBLE WALL 95.UNKNOWN ❑2.DOUBLE WALL ❑99.OTHER MANUFACTURER 465, MANUFACTURER 465. ❑1.BARE STEEL D 6.FRP COMPATIBLE W1100%METHANOL ❑1.BARE STEEL D 6.FRP COMPATIBLE W/100%METHANOL D 2.STAINLESS STEEL D 7.GALVANIZED STEEL �/ D 2.STAINLESS STEEL D 7.GALVANIZED STEEL D 3.PLASTIC COMPATIBLE WITH CONTENTS S.UNKNOWN D 3.PLASTIC COMPATIBLE W/CONTENTS D 9.FLEXIBLE(HDPE) D 99.OTHER ❑4.FIBERGLASS D 8.FLEXIBLE(HDPE) D 99.OTHER D 4.FIBERGLASS D 9.CATHODIC PROTECTION D 5.STEEL W/COATING D 9.CATHODIC PROTECTION 464. D 5.STEEL W/COATING �A95.UNKNOWN 465, VII.PIPING LEAK DETECTION Chas all that I Adeacd ion of the ox.atong P.,oun kkall be submitted w the bW UNDERGROUND PIPING ABOVEGROUND PIPING SINGLE WALL PIPING 466, SINGLE WALL PIPING 467. PRESSURIZED PIPING(Check all that apply): PRESSURIZED PIPING(Check all that apply): D 1. ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP D 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. D 2. MONTHLY 0.2 GPH TEST d 02. MONTHLY 0.2 GPH TEST D 3. ANNUAL INTEGRITY TEST(0,l GPH) N�/ 03. ANNUAL INTEGRITY TEST(0.1 GPH) 04. DAILY VISUAL CHECK CONVENTIONAL SUCTION SYSTEMS CONVENTIONAL SUCTION SYSTEMS(Check all that apply) ❑ S. DAILY VISUAL MONITORING OF PUMPING SYSTEM+TRIENNIAL PIPING E35. DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM INTEGRITY TEST(0.1 GPH) SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): 06. TRIENNIAL INTEGRITY TEST(0.1 GPH) [17. SELF MONITORING - / SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): GRAVITY FLOW A111 fir D 7. SELF MONITORING C39. BIENNIAL INTEGRITY TEST(0.1 GPH) /�f GRAVITY FLOW(Check all that apply): [18. DAILY VISUAL MONITORING 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) D a AUTO PUMP SHUT OFF WREN A LEAK OCCURS D a. AUTO PUMP SHUT OFF WHEN A LEAK OCCURS D b.AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM D b.AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM DISCONNECTION DISCONNECTION {]c. NO AUTO PUMP SHUTOFF Uc, NO AUTO PUMP SHUT OFF [111. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)WITH FLOW SHUT OFF OR RESTRICTION D 11. AUTOMATIC LEAK DETECTOR D 12. ANNUAL INTEGRITY TEST(0.1 GPH) D 12. ANNUAL INTEGRITY TEST(0.1 GPH) SUCTION/GRAVITY SYSTEM SUCTION/GRAVITY SYSTEM D 13. CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS D 13. CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS EMERGENCY GENERATORS ONLY(Check all that apply) EMERGENCY GENERATORS ONLY(Check all that apply) D 14. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF D14. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF AUDIBLE AND VISUAL ALARMS AUDIBLE AND VISUAL ALARMS D 15. AUTOMATIC LINE LEAK DETECTOR (3.0 GPH TEST) WITHOUT FLOW D I5. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TES SHUT OFF OR RESTRICTION TI 016, ANNUAL INTEGRITY TEST(0.1 OPH) D 16. ANNUAL INTEGRITY TEST(0.1 GPH) (j 17. DAILY VISUAL CHECK 017. DAILY VISUAL CHECK VIII.DISPENSER CONTAINMENT DISPENSER CONTAINMENT 468. 01, FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE 04. DAILY VISUAL CHECK 469. DATE INSTALLED E12. CONTINUOUS DISPENSER PAN SENSOR+AUDIBLE AND VISUAL ALARMS D 5./TRENCH/LINER MONITORING U1I/l liND6n) nJ I P D � 3. CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR WK NONE DISPENSER+AUDIBLE AND VISUAL ALARMS IX-OWNER/OPERATOR SIGNATURE Lcw&that the in rmation provitlyd herein is)true and accurate to the best of my knowledge. NA OFO ER/ TO DATE: 470 a� NAMEOFO PER t); TITLE OF OWNFR/OPERATO 4-n Permit N=Ver(Agency we only) 471. Permit App oved By(Agency use only) 474. 1 Permit Expiration Date(Agency use only) 475. UPCF hwfwrc-b(1/99)-3/4 http://www-unidoc&org Rev.02116/00