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C p, U4rD PROGRAM CONSOLIDATED EO TANKS UNDERGROUND STORAGE TANKS - TANK PAGE 2 Pae of Z VI.PIPING CONSTRUCTION Cheek alt thatapply) UNDERGROUND PIPING ABOVEGROUND PIPING SYSTEM TYPE 1.PRESSURE [12.SUCTION ❑3.GRAVITY 458. ❑1.PRESSURE ❑2.SUCTION ❑3.GRAVITY 459. CONSTRUCTION/ SINGLE WALL ❑3.LINED TRENCH ❑99.OTHER 460. ❑ 1.SINGLE WALL El95.UNKNOWN 462. MANUFACTURER 2.DOUBLE WALL ❑95.UNKNOWN ®2.DOUBLE WALL ❑99.OTHER MANUFACTURER 461, MANUFACTURER 463. ❑I.BARE STEEL ❑6.FRP COMPATIBLE W/100%METHANOL ❑ 1.BARE STEEL - ❑6.FRP COMPATIBLE W/100%METHANOL ❑2,STAINLESS STEEL ❑7.GALVANIZED STEEL ❑2.STAINLESS STEEL ❑7,GALVANIZED STEEL k4, PLASTIC COMPATIBLE WITH CONTENTS ❑95.UNKNOWN ❑3.PLASTIC COMPATIBLE W/CONTENTS C18.FLEXIBLE(HDPE) ❑99.OTHER FIBERGLASS ❑8.FLEXIBLE(HDPE) ❑99.OTHER ❑4.FIBERGLASS ❑9.CATHODIC PROTECTION ❑S.STEEL WICOATING ❑9.CATHODIC PROTECTION 464. ❑5.STEEL WICOATING ❑95.UNKNOWN 465. VII.PIPING LEAK DETECTION Check all that apply) A descri pan of the moaltoring prognmshall be submitted to the local a ea 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 GPM TEST WIC[ AUTO PUMP ❑1. ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST L; ,{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 ❑2. MONTHLY 0.2 GPH TEST ❑3. ANNUAL INTEGRITY TEST(0.1 GPH) ❑3. ANNUAL INTEGRITY TEST(0.1 GPH) ❑4. 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) El5. DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): ❑6. TRIENNIAL INTEGRITY TEST(0.1 GPH) [17. SELF MONITORING SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): GRAVITY FLOW ❑7. SELF MONITORING 09. BIENNIAL INTEGRITY TEST(0.1 GPH) GRAVITY FLOW(Check all that apply): ❑S. DAILY VISUAL MONITORING ❑9. 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 W)M AUDIBLE AND VISUAL 10. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL ALARMS AND(Check one) ALARMS AND(Check ane) A 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 ❑e. NO AUTO PUMP SHUT OFF ❑c. NO AUTO PUMP SHAG OFF 11. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)WITH FLOW SHUT OFF OR RESTRICTION ❑11. AUTOMATIC LEAK DETECTOR ❑12. ANNUAL INTEGRITY TEST(0.1 GPH) ❑12. ANNUAL INTEGRITY TEST(0.1 GPH) SUCTION/GRAVITY SYSTEM SUCTIONIGRAVITY SYSTEM ❑ 13. CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS ❑13. CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS EMERGENCY 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 WITHOUT 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 ❑15. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST) ❑ 16. ANNUAL INTEGRITY TEST(0.1 GPH) ❑ 16. ANNUAL INTEGRITY TEST(0.1 GPH) ❑ 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 912. CONTINUOUS DISPENSER PAN SENSOR+AUDIBLE AND VISUAL ALARMS ❑5. TRENCH/LINER MONITORING �l/y��,� ❑3. CONTINUOUS DISPENSER PAN SENSOR W AUTO SHUT OFF FOR ❑6. NONE ! DISPENSER+AUDIBLE AND VISUAL ALARMS DC.OWNER/OPERATOR SIGNATURE I certify that t1p infbrrrmion provided herein is true and accurate to the best of my knowledge. SIGNA F 0R/OP TOR DATE: 470. 2 -a NAME OF OWNER/OPERATOR(print): TITLE OF OWNER/OPERATOR: f Permit Number(Agency use only) 473. Permit Approved By(Agency use only) 474. 1 Permit Expiration Date(Agency use only) 475. UPCF hwfwrc-b(1199)-314 http://www.unidocs.org Rev.02il6/00