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- UNIFIED PROGRAM CONSOLIDATED FORM - TANKS UNDERGROUND STORAGE TANKS-TANK PAGE 2 :,.'u _,':;' >•,,,-'•......., r 'A.a 1M1 PI PINGCO NS TRUcTz NIcro 'a4fMtappy ... - UNDERGROUND PIPING ABOVEGROUND PIPING SYSTEM TYPE �K1 PRESSURE ❑ 2.SUCTION ❑ 3. GRAVITY ❑ 1.PRESSURE ❑ 2. SUCTION ❑ 3.GRAVITY` CONSTRUCTION/ 13 1.SINGLE WALL ❑3.UNEDTRENCM ❑N.OTHER ❑ 1.SINGLE WALL 1195. UNKNOWN - MANUFACTURER �Q 2. DOUBLE WALLI,� UNKNO'M� �ry ` 132 DOUBLE WALL ❑99. OTHER - - •W3)IUFACTURER �( R-L/ ' MANUFACTURER ❑ 1.BARE STEEL ❑ B. FRPCOMPATIBLEW/100%METIANOL - ❑ 1.BARE STEEL ❑ 8. FRPCOMPATBLEW/1W%METHANOL MATERIALS AND ❑ 2 STAINLESS STEEL ❑ T.GALVANIZED STEEL ❑ 2.STAINLESS STEEL ❑ T. GALVANIZED STEEL CORROSION - PROTECTION ]. PLASTIC COMPATIBLE VATH CONTENTS 095. UNKNOWN ❑ ].PLASTICCOMPATIBLEWITHCONTENTS ❑ S. FLEXIBLE(NOPE) ❑9%OTHER �4. FIBERGLASS ❑ S. FLEXIBLE(HDPE) ❑B9.OTHER ❑4. FIBERGLASS ❑ 9.CATMOOICPROTECTION ❑ S.STEELWICOATING ❑ 9.CATHODIC PROTECTION - ❑ 5. STEEIWICOATING 095. UNKNOWN - - r; - VILPIPINGLEAKDETECTION UNDERGROUND PIPING ABOVEGROUND PIPING - SMGLEWALLPIPING SINGLE W LLPIPING PRESSURIZED PIPING(CMab4fnaf apply]: PRESSURIZED PIPING(GMck al Naf apply): ❑ 1. ELECTRONIC UNE LEAK DETECTOR 3.0 GPM TEST WTH AUTO PUMP SHUT OFF FOR ❑ /.ELECTRONIC LINE LEAK DETECTOR 3.0 GPM TEST WITH AUTO PUMP SHUT OFF FOR LEAK LEAK SYSTEM FAILURE.AND SYSTEM OISCONNECTtON•AUDIBLE AND VISUAL SYSTEM FAILURE.AND SYSTEM DISCONNECTION•AUDIBE AND VISUAL ALARMS ALARMS ❑ 2.MONTHLY 0.2 GPM TEST ❑ 2. MONTHLY DS GPM TEST ❑ M ❑ ].ANNUAL INTEGRITY TEST(0.1 GPM) 3.ANNUAL INTEGRITY TEST IDA GP ❑ 4.DAILY VISUAL CHECK CONVENTIONAL SUCTION SYSTEMS: CONVENTIONAL SUCTION SYSTEMS(CAwk&Z Mal apPW: ❑ S.DAILY VISUAL MONITORING OF PUMPING SYSTEM•TRIENNIAL PIPING INTEGRITY S.DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM _ TEST IDA GPM) ❑ B TRIENNIAL INTEGRITY TEST IDA GPM) SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING)I SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): ❑ T.SELF MONITORING ❑ T.SELF MONITORING - GRAVITY FLOW. GRAVITY FLOW(CMck a4 Mal apply): ❑ 9. BIENNIAL INTEGRITY TEST IDA GPM) ❑ 8,DAILY VISUAL MONITORING - ❑ 9. BIENNIAL INTEGRITY TEST(0.1 GPM) SECONDARILY CONTAINED PIPING SECONDARILY CONTAINED PIPING PRESSURIZED PIPING(Cnacat all Mat appy): PRESSURIZED PIPING(Cneoie a4 Mat appY/: - 10. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL ALARMS AND - - (CneU Ona) 10.CONTINUOUS TURBINE SUMP SENSOR`MTH AUDIBLE AND VISUAL ALARMS AND(( e&one) e. AUTO PUMP SHUT OFF GASMEN A LEAK OCCURS ❑a.AUTO PUMP SHUT OFF WHEN A LEAK OCCURS AUTB. DISCONMP NECTION OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM ❑p,AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM DISCONNECTION DISCONNECTION ❑ e NO AUTO PUMP SHUT OFF ❑ C NO AUTO PUMP SHUT OFF ❑ 11.AUTOMATIC LINE LEAK DETECTOR(3.0 GPM TEST)VATH FLOW SHUT OFF OR RESTRICTION ❑ 11.AUTOMATIC LEAK DETECTOR ❑ 12.ANNUAL INTEGRITY TEST IDA GPM) ❑ 12 ANNUAL INTEGRITY TEST(0.1 GPM) SUCTIOWGRAVITY SYSTEM: SUCTIONIGRAVITY SYSTEM: ❑ U.CONTINUOUS SUMP SENSOR-AUDIBLE AND VISUAL ALARMS 013.CONTINUOUS SUMP SENSOR•AUDIBLE AND VISUAL ALARMS EMERGENCY G ENERATORS ONLY(Cnack.1lnafappM EMERGENCY GENERATORS ONLY(Cneck a4 Mat appal - ❑ 14.CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF•AUOIBLE AND ❑ 14.CONTINUOUS SUMP SENSOR WTHOUT AUTO PUMP SMUT OFF•AUDIBLE AND VISUAL VISUAL ALARMS ALARMS - [] 15.AUTOMATIC LINE LEAK DETECTOR(].0 GPM TEST)WITHOUT FLOW SHUT OFF OR ❑ 15.AUTOMATIC UNE LEAN DETECTOR(].0 GPH TEST) RESTRICTION ❑ 18.ANNUAL INTEGRITY TEST(0.1 GPM) ❑ 18.ANNUALINYEGRITYTEST(0.1GPH) ❑ 17.MLYVISUALCMECK ❑ 17.DAILYVISUALCMECK - . l _ VIAL DISPENSER CONTAINMENT -- fY. � :. DISPENSER CONTAINMENT ❑ L FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE ❑ 4. OAILYVISUALCHECK OATEINSTALLEO NN11 ❑ 2. CONTINUOUS DISPENSER PAN SENSOR•AUDIBLE AND VISUAL ALARMS ❑ S.TRENCH LINER/MONITORING PrA. CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SMUT OFF FOR DISPENSER.AUDIBLE AND VISUAL ALARMS ❑ B. NONE UL OWNER/OPERATOR SIGNATURE I cony that Me Infatna8pn pnoold"Hens.Is bVe andte IF the fleat of my H eE9e. SIGNATURE OF OWNERACPERATOR DATE C NA.MEOFOWNER/OPERATOR M0 TITLE OF OWNEWOPERATOR PpmB NumOw(Fplbcal uae only) Pertrvl ApPrvveB(fw lou/uu anlyJ � Pe�4 EFpiratlan Dab(Forkvul uae amyl CUPAFORM(4199) Formerly$VVRCR Form B