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r L§VffD PROGRAM CONSOLIDATED FORW TANKS UNDERGROUND STORAGE TANKS - TANK PAGE 2 VI.PIPING CONSTRUCTION Check all that apply) UNDERGROUND PIPING ABOVEGROUND PIPING SYSTEM TYPE 1.PRESSURE ❑2.SUCTION ❑3.GRAVITY 458. ❑1.PRESSURE ❑2.SUCTION ❑3.GRAVITY 439. CONSTRUCTION/ 0 SINGLE WALL ❑3.LINED TRENCH ❑99.OTHER 460. ❑ I.SINGLE WALL ❑95.UNKNOWN 462. MANUFACTURER 2 DOUBLE WALL ❑95.UNKNOWN ❑2.DOUBLE WALL ❑99.OTStIER MANUFACTURER 461. MANUFACTURER 463. ❑1.BARE STEEL [16.FRP COMPATIBLE W1100%METHANOL ❑1.BARE STEEL ❑6.FRP COMPATIBLE W/100%METHANOL ❑2.STAINLESS STEEL El 7.GALVANIZED STEEL ❑2.STAINLESS STEEL ❑7.GALVANIZED STEEL PLASTIC COMPATIBLE WITH CONTENTS 1195.UNKNOWN ❑3.PLASTIC COMPATIBLE W/CONTENTS [18.FLEXIBLE(HDPE) 1199.OTHER 4.FIBERGLASS ❑8.FLEXIBLE(HDPE) ❑99,OTHER ❑4.FIBERGLASS ❑9.CATHODIC PROTECTION ❑5.STEEL W/COATING ❑9,CATHODIC PROTECTION 464. ❑S.STEEL WICOATING ❑95.UNKNOWN 465_ VII.PIPING LEAK DETECTION(Check all that apply) A deasYi don of the monitoring prognunshill 6e submitted to the local agency.) UNDERGROUND PIPING ABOVEGROUND PIPING SINGLE WALL PIPING 466. SINGLE WALL PIPING 467. PRESSURIZED PIPING(Check all that apply): PRESSURIZED PIPING(Check all that apply): [] 1. ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST W__ITH AUTO PUMP [11. ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WYM 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. ❑2. MONTHLY 0.2 GPH TEST 02. MONTHLY 0.2 GPH TEST ❑3. ANNUAL INTEGRITY TEST(0.1 GPH) ❑3. ANNUAL INTEGRITY TEST(0.1 GPH) 114. DAILY VISUAL CHECK CONVENTIONAL SUCTION SYSTEMS CONVENTIONAL SUCTION SYSTEMS(Check all that apply) ❑5. DAILY VISUAL MONITORING OF PUMPING SYSTEM+TRIENNIAL PIPING INTEGRITY TEST(0.1 GPH) ❑5 DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): [36. TRIENNIAL INTEGRITY TEST(0.1 GPH) 0 7. SELF MONITORING SAFE SUCTION SYSTEMS(NO VALVES 1N BELOW GROUND PIPING): GRAVITY FLOW ❑7. SELF MONITORING ❑9. BIENNIAL INTEGRITY TEST(0.1 GPH) GRAVITY FLOW(Check all that apply): ❑8. DAILY VISUAL MONITORING E19- 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 )U AUDIBLE AND VISUAL ALARMS AND(Check one) ALARMS AND(Check one) IN a. AUTO PUMP SHUT OFF WHEN A LEAK OCCURS ❑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 DISCONNECTION DISCONNECTION ❑c. NO AUTO PUMP SHUT OFF ❑c. NO AUTO PUMP SHUT OFF I. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)WITH FLOW SHUT ❑ OFF OR RESTRICTION 1 I AUTOMATIC LEAK DETECTOR ❑12. ANNUAL INTEGRITY TEST(0.1 GPH) ❑12. ANNUAL INTEGRITY TEST(0.1 GPH) SUCTION/GRAVITY SYSTEM SUCTION/GRAVITY SYSTEM ❑ 13. CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS ❑ 13. CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS ENIERGENCY GENERATORS ONLY(Check all that apply) EMERGENCY GENERATORS ONLY(Check all that apply) ❑ 14. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF ❑ 14. CONTINUOUS SUMP SENSOR Wi �E�QUT AUTO PUMP SHUT OFF AUDIBLE AND VISUAL ALARMS AUDIBLE AND VISUAL ALARMS ❑ 15. AUTOMATIC LINE LEAK DETECTOR (3.0 GPH TEST) WITHOUT FLOW SHUT OFF OR RESTRICTION I� 15. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST) ❑ 16. ANNUAL INTEGRITY TEST(0.1 GPH ❑16. ANNUAL INTEGRITY TEST(0.1 GFH) ❑ 17. DAILY VISUAL CHECK ❑ 17. DAILY VISUAL CHECK VIII.DISPENSER CONTAINMENT DISPENSER CONTAINMENT 468. ❑ 1. FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE ❑4. DAILY VISUAL CHECK 469. DATE INSTALLED W12. CONTINUOUS DISPENSER PAN SENSOR+AUDIBLE AND VISUAL ALARMS ❑5. TRENCH/LINER MONITORING ,f 10,j 1:13. CONTINUOUS DISPENSER PAN SENSOR �YM AUTO SHUT OFF FOR ❑6 NONE f DISPENSER+AUDIBLE AND VISUAL ALARMS M.OWNER/OPERATOR SIGNATURE [certify that t information provided herein is true and accurate to the best of my knowledge. SIGNATU F 0 RfOP TOR DATE: 470. -t;5 NAME OF OWNER/OPERATOR(print):� TITLE OF OWNER/OPERATOR: 4 n Permit Number(Agency use only) 473 1 Permit Approved By(Agency use only) 474, Permit Expiration Date(Agency use only) 475. UPCF hwfwrc-b(1/99)-314 http://www.unidoes.org Rev.02/16x00