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I y 13 UNIFIED PROGRAM CONSOLIDATED FORM TANKS UNDERGROUND STORAGE TANKS -T NK PAGE 2 Page of dj / VLYIPINGCONSTRUCTION(cheakeauw. 1 ABOVEGROUND PIPING UNDERGROUND PIPING SYSTEM TYPE E 1.PRESSURE E 2.SUCTION ❑3.GRAVITY 458. ❑I.PRESSURE [12.SUCTION E 3.GRAVITY 462 CONSTRUCTION/ E L SINGLE WALL [13.LINED TRENCH E 99.OTHER 460. ❑1.SINGLE WALL ®95.UNKNOWN J MANUFACTURER E 2.DOUBLE WALL M95.UNKNOWN ❑2.DOUBLE WALL E 99.OTHER 461. MANUFACTURER MANUFACTURER 6.PEP COMPATIBLE W/100%METHANOL E I BARE STEEL [16.PRP COMPATIBLE W/100%METHANOL ❑1.BARE STEEL ❑2.STAINLESS STEEL E 7.GALVANIZED STEEL E 2.STAINLESS STEEL ❑7.GALVANIZED STEEL ❑3.PLASTIC COMPATIBLE WITH CONTENTS &95.UNKNOWN [13.PLASTIC COMPATIBLE W/CONTENTS ❑S.ANODIC BLE PROTECTION ❑99OTHER ❑4.FIBERGLASS ❑S.FLEXIBLE(HDPE) ❑99.OTHER [14.FIBSTEL LASSW/CO 465. ❑5.STEEL W/COATING ❑9.CATHODIC PROTECTION 464, ❑5.STEEL W/COATING ®.95.UNKNOWN ow VII.PIPING LEAK DETECTION(Check ell inu N (Adescri oonoftha rrovitorin ro !E BREGIRO DIONFINGeq ) UFIDERGAOUND PIPING 467. SINGLE WALL PIPING Ors. SINGLE WALL PIPING PRESSURIZED PIPING(Check all than apply): _ PRESSURIZED PIPING(Check all that apply): 1. T WITH AUTO SELECTRONIC HUT-O PNFOR L AKLEAK.SYSTEM EFAIOLURE, T WITH AUTO PUMP AND SYSTEM DISCONNECTION I ELECTRONICFOR LEAK SYSTEM FAILURE,APND 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.l GPR) E 4. DAILY VISUAL CHECK CONVENTIONAL SUCTION SYSTEMS CONVENTIONAL SUCTION SYSTEMS(Check all that apply) []5. DAILY VISUAL MONITORING OF PUMPING SYSTEM+TRIENNIAL PIPING 05. DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM INTEGRITY TEST(0.1 GPH) SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): FE S6. UCTION ONS STEMS(No ENNIAL INTEGRITY VALVES G SN BELOW GROUND PIPING): E 7. SELF MONITORING []7, SELF MONITORING GRAVITY FLOW GRAVITY FLOW(Check all I 09 BIENNIAL INTEGRITY TEST(0.1 GPH) ❑8. DAILY VISUAL MONITORING apply): E 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 WITH AUDIBLE AND VISUAL 10. AG„ AND(Check one) SUMP SENSOR WITH AUDIBLE AND VISUAL one) ALARMS AND(Check one) ❑e. AUTO PUMP SHUT OFF WHEN A LEAK OCCURS E 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 Ec. NO AUTO PUMP SHUT OFF E11. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)WITH FLOW SHUT E 11.AUTOMA71C LEAK DETECTOR OFF OR RESTRICTION E 12.ANNUAL INTEGRITY TEST(0.1 GPH) E 12, ANNUAL INTEGRITY TEST(0.1 GPH) SUCTION/GRAVITY SYSTEM SUCTION/GRAVITY SYSTEM 13. CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS E l3.EMERGENCY GENERATORS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS EMERGENCY GENERATORS ONLY(Check all to a apply) EMERGENCY GENERATORS ONLY(Check all that apply) 14. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF C]14+ CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF E AUDIBLE AND VISUAL ALARMS AUDIBLE AND VISUAL ALARMS ❑15. AUTOMATIC LINE LEAK DETECTOR (3.0 GPH TEST) WITHOUT FLOWE 15.AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST) SHUT OFF OR RESTRICTION E 16,ANNUAL INTEGRITY TEST(0.1 GPR) []16, ANNUAL INTEGRITY TEST(0.1 GPH) E 17.DAILY VISUAL CHECK []17. DAILY VISUAL CHECK VIIL DISPENSER CONTA LE4 DAILY VISUAL CHECK 469. DISPENSERCONTAINMENT 468. E1. FLOAT MECHANISM THAT SHUTS OFF SHEAR VAVALVE DATE INSTALLED E]2. CONTINUOUS DISPENSER PAN SENSOR+AUDIBLE AND VISUAL ALARMS [15. TRENCH/LINER MONITORING []3. CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR []6. NONE DISPENSER+AUDIBLE AND VISUAL ALARMS IX.OWNER/OPERATOR SIGNATURE I certify that the information provided herein is true and accurate to the best Of my knowledge. 470 DATE: 1 NATUR F IUO ATOR 472. TITLE OF O PERATOR: Pemd[Number(Agency use only) 473. Penni[Approved By(Agency use only) 474. Permit Expiation Date(Agency use only) 475. Rev.02/16M UPCF hwfwrc-b(1/99)-3/4 bttp://www.unidocs.org I