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UNIFIED PROGRAM CONSOLIDATED FORZ TANKS , 1 ra-(1 D UNDERGROUND STORAGE TANKS -TANK PAGE 2 �� YI.PDfYNG<CONSTRUCTION Id hat l Pae of UNDERGROUND PIPWG SYSTEM TYPE ❑1.PRESSIBtBPQ Z.SUCTION ABOVEGROUND PIPING CONSTRUCTION/ L SINGLE WALL ❑3.GRAVITY 45i. ❑I.PRESSURE ❑2.SUCTION ❑3.GRAVITY ass. MANUFACTURER ❑3.LINED TRENCH ❑99.OTHER 460. p'1,SINGLE WALL O 2.DOUBLE WALL 5.UNKNOWN ❑95.UNKNOWN 462. MANUFACTURER ❑2.DOUBLE WALL ❑99.OTHER ❑1.BARE STEEL ❑6.FRP COMPATIBLE W/100°/.METHANOL 461. MANUFACTURER ❑L BARE STEEL 465' ❑2.STAINLESS STEEL ❑7.GALVANIZED STEEL [36.FRP COMPATIBLE W/100%METHANOL El3.PLASTIC COMPATIBLE WITH CONTENTS ❑2.STAINLESS STEEL ❑7.GALVANIZED STEEL ❑4.FIBERGLASS Q5,UNKNOWN ❑3.PLASTIC COMPATIBLE W/CONTENTS ❑8.FLEXIBLE(HDPE) ❑99.OTHER ❑8.FLEXIBLE(HDPE) 1199.OTHER El 3.STEEL W/COATING ❑9.CATHODIC PROTECTION d 4.FIBERGLASS ❑9.CATHODIC PROTECTION W ❑5.STEEL W/COATING UNKNOWN YII. PIPING LEAK DETECTION Check Jikat I A:aescritwn enheivanfiodn m mslWl;tiEsubmil'edio tbq b'pl ene 46s. UNDERGROUND PIPING SINGLE WALL PIPING ABOVEGROUND PIPING PRESSURIZED PIPING(Check all that apply): 466, SINGLE WALL PIPING PP y)' PRESSURIZED PIPING(Check all that apply): 467. 0 1. ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP SHUT-OFF FOR LEAK,SYSTEM FAILURE,AND SYSTEM DISCONNECTION 0 1. ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP +AUDIBLE AND VISUAL ALARMS, SHUT OFF FOR LEAK,SYSTEM FAILURE,AND SYSTEM DISCONNECTION ❑2. MONTHLY 0.2 GPH TEST +AUDIBLE AND VISUAL ALARMS, [32. MONTHLY 0.2 GPH TEST 3. ANNUAL INTEGRITY TEST(0.1 GPH) / K� �J ❑3. ANNUAL INTEGRITY TEST(0.1 GPH) CONVENTIONAL SUCTION SYSTEMS /7 04. DAILY VISUAL CHECK N ,G TRIENNIAL PI ❑5. DAILY VISUAL MONITORING OF PUMPING SYSTEM+ CONVENTIONAL SUCTION SYSTEMS(Check all that apply) // INTEGRITY TEST(0.1 GPH) PING 115. DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): [16. TRIENNIAL INTEGRITY TEST(0,1 GPH) E17. SELF MONITORING GRAVITY FLOW SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): 117, SELF MONITORING E19. BIENNIAL INTEGRITY TEST(0.1 GPH) j GRAVITY FLOW(Check all that apply): N ❑8. DAILY VISUAL MONITORING SECONDARILY CONTAINED PIPING 09. BIENNIAL INTEGRITY TEST(0.1 GPH) PRESSURIZED PIPING(Check all that apply): SECONDARILY CONTAINED PIPING Pp y)' 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 anej ❑a AUTO PUMP SHUT OFF WHEN A LEAK OCCURS ALARMS AND(Check one) STEM a AUTO PUMP SHUT OFF WHEN A LEAK OCCURS ❑b. AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM ❑b.AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM Dc. NO AUTO PUMPSHUT OFF DISCONNECTION 011. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)WITH FLOWSHUT 0e' NO AUTO PUMP SHUTOFF OFF OR RESTRICTION ❑11.AUTOMATIC LEAK DETECTOR ❑12. ANNUAL INTEGRITY TEST(0.1 GPH) SUCTION/GRAVITY SYSTEM 12.ANNUAL INTEGRITY TEST(0.1 GPH) SUCTION/GRAVITY SYSTEM [113- CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS EMERGENCY GENERATORS ONLY(Check all that apply) ❑ E CONTINUOUS SUMP SENSOR+gUDIBLE AND VISUAL ALARMS ❑14. CONTINUOUS SUMP SENSOR O y) EMERGENCY GENERATORS ONLY(Check all that apply) AUDIBLE AND VISUAL ALARMS �A�OPUMPSHUTOFF [3 14. CONTINUOUS SUMP SENSOR WI PPP ❑ I5. AUTOMATIC UNE LEAK DETECTOR 3.0 GPH TES W AUDIBLE AND VISUAL ALARMS ��AUTO PUMP SHUT OFF SHAT OFF OR RESTRICTION ( T) --�- FLOW [115. AUTOMATIC LINE LEAK DETECTOR(3.0 GPN TEST) ❑l6. ANNUAL INTEGRITY TEST(0.1 GPH) ❑17. DALLY VISUAL CHECK ❑16. ANNUAL INTEGRITY TEST(0,1 GPH) ❑V. DAILY VISUAL CHECK VIIi.DIS$ENSER COIITAIN ' rg DISPENSER CONT:=;//101 FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE DATE INSTALLEDCONTINUOUS DISPENSER PAN SENSOR+AUDIBLE AND VISUAL ALARMS 4. DAILY VISUAL CHECK dbs. � CONTINUOUS DISPENSER PAN SENSOR W �5 TRENCH/LINER MONITORING _�j AUTO SHUT OFF FOR �5�2 DISPENSER AND VISUAL CABINS Y\ NONE IX.OWNERJOPERATOR SICNATUlEi1 TU O E MR . cert' that the in short Prov' -herein is a and accurate to the best of my knowledge. DATE: i-1 �l �� 11G NAMEOFO OF OR(p' [): TITLE OF OWNER/OPERATOR:� 4Tx. Pemtit N=I r( gency use anly) - 475. Permit A p ved By(Agency use only) nd. Permit Expiration Date(Ageoey m<oNY) ns. J UPCF hwlwrc-b(1N9)-3/4 htip://www,unidocsorg Rev.021/6/00