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IED PROGRAM CONSOLIDATED FO 1 TANKS UNDERGROUND STORAGE TANKS - TANK PAGE 2 Pae of VI.PIPING CONSTRUCTION(Ch«k all thatapply) UNDERGROUND PIPING ABOVEGROUND PIPING SYSTEM TYPE 1.PRESSURE [12.SUCTION ❑3.GRAVITY 458. ❑ 1.PRESSURE ❑2.SUCTION ❑3.GRAVITY 459. CONSTRUCTION/ ❑ L SINGLE WALL ❑3.LINED TRENCH ❑99.OTHER 460. ❑ 1.SINGLE WALL ❑95.UNKNOWN 462. MANUFACTURER 2 DOUBLE WALL ❑95.UNKNOWN ❑2.DOUBLE WALL ❑94.OTHER MANUFACTURER 461. MANUFACTURER 463. ❑ 1.BARE STEEL ❑6.FRI COMPATIBLE W/100%METHANOL ❑1.BARE STEELu ❑6.FRP COMPATIBLE W1104/a METHANOL ❑2.STAINLESS STEEL ❑7.GALVANIZED STEEL ❑2.STAINLESS STEEL ❑7.GALVANIZED STEEL [13.PLASTIC COMPATIBLE WITH CONTENTS ❑95.UNKNOWN ❑3.PLASTIC COMPATIBLE W1 CONTENTS ❑8.FLEXIBLE(HDPE) ❑99.OTHER K4.FIBERGLASS (:18.FLEXIBLEE(HDPE) [199.OTHER [14.FIBERGLASS ❑9.CATHODIC PROTECTION 5.STEEL W/COATING ❑9.CATHODIC PROTECTION 464. ❑5.STEEL W/COATING ❑95.UNKNOWN 465. VII.PIPING LEAK DETECTION(Check all that apply) A ription of the monkoflng prognunshall be 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 WITH AUTO PUMP ❑ I. ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST MM 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.l GPH) ❑5. DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): C16. TRIENNIAL INTEGRITY TEST(0.1 GPH) ❑T SELF MONITORING SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): GRAVITY FLOW ❑7. SELF MONITORING [19. 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 WrM AUDIBLE AND VISUAL 10. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL ,A�LARMS AND(Check one) ALARMS AND(Check one) L {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 A 11, AUTOMATIC LINE LEAK DETECTOR(3.0 GFH TEST)WITH FLOW SHUT ❑ OFF OR RESTRICTION 11 AUTOMATIC LEAK DETECTOR [112. 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 [1l5. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TES SHUT OFF OR RESTRICTION ( T) ❑ 16. ANNUAL INTEGRITY TEST(0.1 GPH) ❑ 16. ANNUAL INTEGRITY TEST(0.1 GPH) ❑17. DAILY VISUAL CHECK [117. DAILY VISUAL CHECK VIIL DISPENSER CONTAINMENT DISPENSER CONTAINMENT 468. ❑ 1. FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE ❑4. DAILY VISUAL CHECK 469. DATE INSTALLED X2. CONTINUOUS DISPENSER PAN SENSOR+AUDIBLE AND VISUAL ALARMS ❑5. TRENCH/LINER MONITORING �,�, [13. CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR ❑6 NONE `T! DISPENSER+AUDIBLE AND VISUAL ALARMS LY.OWNER/OPERATOR SIGNATURE 1 certify that the infi6mation provided herein is true and accurate to the best of my knowledge. SIGNATURE O WNE PERA DATE: 470 NAME OF OWNEWOPERATOR(print):�,. TITLE OF OWNERIOPERATOR; 472. 90 Permit Number(Agency use only) 473. 1 Permit Approved By(Agency use only) 474. 1 Permit Expiration Date(Agency use only) 475. UPCF hwfwre-b(1199)-3/41 http://www.urLidoes.org Rev.02/16/00