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-•-<aU _ '•NIFIED PROGRAM CONSOLIDATED FOR TANK: TA0508320`a( PR#: PR0231761 FAC#: FA0002347 UNDERGROUND STORAGE TANKS - TANK PAGE 2 3 Dy VI.PIPING CONSTRUCTION(Clack all Na apply) Page 3 of7 UNDERGROUND PIPING AHOVEGROUND PIPING SYSTEMTYPE (.PRESSURE ❑ 2.SUCTION ❑ 3.GRAVITY 458 ❑ I.PRESSURE ❑2.SUCTION ❑ 3.GRAVITY 459 CONSTRUCTION ...accaaa❑�aayffLSMGLE WALL [:13.LINED TRENCH ❑99.OTHER 460 ❑ I.SINGLE WALL ❑ 95.UNKNOWN 462 2.DOUBLE WALL ❑95.UNKNOWN ❑ 2.DOUBLE WALL ❑ 99.OTHER MANUFACTURER/X1061 MANUFACTURER 463 ❑ 1.BARE STEEL ❑6.FRP COMPATIBLE w/I99R METHANOL ❑ 1.BARE STEEL ❑ 6.FRP COMPATIBLE w/1(aM METHANOL ❑ 2.STAINLESS STEEL ❑ 7.GALVANIZED STEEL ❑ 2.STAINLESS STEEL ❑ 7.GALVANIZED STEEL ❑ PLASTIC COMPATIBLE W/CONTENTS ❑ 95.UNKNOWN ❑ PLASTIC COMPATIBLE W/CONTENTS ❑95.UNKNOWN 04.FIBERGLASS ❑ S.FLEXIBLE(HDPE) ❑ 99.OTHER ❑ 4.FIBERGLASS ❑ S.FLEXIBLE(HDPE) [:199.OTHER ❑ 5.STEEL W/COATING [19.CATHODIC PROTECTION _ 464 ❑ 5.STEEL W/COATING ❑ 9.CATHODIC PROTECTION 465 VO.PIPING LEAK DETECTION(Chale all that apply)(A 4caip6oaOfftm -mgpmgraashall be Bubm fleito th,loos agaay.) UNDERGROUND PIPING ABOVEGROUND PIPING SINGLE WALL PIPING 466 SINGLE WALL PIPING 467 PRESSURIZED PIPING(Check all that apply): PRESSURIZED PIPING(Check all that apply): ❑ L ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP SHUT OFF ❑ 1.ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP SHUT OFF FOR LEAK,SYSTEM FAILURE,AND SYSTEM DISCONNECTION+AUDIBLE AND FOR LEAK,SYSTEM FAILURE,AND SYSTEM DISCONNECTION+AUDIBLE AND VISUAL ALARMS. 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(Check all that apply) CONVENTIONAL SUCTION SYSTEMS ❑ 5.DAILY VISUAL MONITORING OF PUMPING SYSTEM+TRIENMEAL PIPING ❑ 5.DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM INTEGRITY TEST(0.1 GPH) ❑ 6.TRIENNIAL INTEGRITY TEST(0.1 GPH) SAFE SUCTION SYSTEMS(No VALUES IN BELOW GROUNDPIPING): SAFE SUCTION SYSTEMS(NO VALUES IN BELOW GROUNDPIPING): ❑ 7.SELF MONITORING ❑ 7.SELF MONITORING GRAVITY FLOW GRAVITY FLOW(Check all that apply): ❑ 9.BIENNIAL INTEGRITY TEST(0.1)GPH ❑ g.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 WITH AUDIBLE AND VISUAL 10.CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL ALARMS AND(Chalcooc) ALARMS AND(Chale onc) C] a.AUTO PUMP S14UT OFF WHEN A LEAK OCCURS E] a.AUTO PUMP SHOFF WHEN A LEAK OCCURS ❑b.AUTO PUMP SHUT OFF FOR LEAKS.SYSTEM FAILURE AND SYSTEM ❑b.AUTO PUMP SHUT T OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM DISCONNECTION DISCONNECTION ® c.NO AUTO PUMP SHUT OFF ❑c.NO AUTO PUMP SHUT OFF ❑ It.AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)WITH FLOW SHUT OFF OR ❑ 11.AUTOMATIC LEAK DETECTOR RESTRICTION ❑ 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 EMERGENCY GENERATORS ONLY(Chale a04a1 apply) EMERGENCY GENERATORS ONLY(Chock all Wa 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 ❑ 15.AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)WITHOUT FLOW ElSHUT OFF OR RESTRICTION SHUT OFF OR RESTRICTION ❑ 16.ANNUAL INTEGRITY TEST(0.1 GPH) ❑ 16.ANNUAL INTEGRITY TEST(0.1 GPH) ❑ 17.DAILY VISUAL CHECK ❑ I].DAILY VISUAL CHECK VIII.DISPENSER CONTAINMENT DISPENSER CONTAINMENT ® 1.FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE ❑4.DAILY VISUAL CHECK DATE INSTALLED 468 ❑ 2.CONTINUOUS DISPENSER PAN SENSOR+AUDIBLE AND VISUAL ALARMS ❑ 5.TRENCH LINER/MONITORING ❑ 3.CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR ❑ 6.NONE 469 DISPENSER+AUDIBLE AND VISUAL ALARMS UL OWNER/OPERATOR SIGNATURE l aetiy nut the informtf2l h dam nclolhcbalofmy lcmc SIGNATURE OF O NE P DATE 470 NAMEOFOWNER/O TO riat) TITLE OF OWNER/OPERATOR 4]I 4]2 Pcmtit Numbef(Forlaalaaeonly) 473 Pamir Appmval(Falaaluseonty) 474 Pamir EVnlimn 1c(Forlaaluaconly) 475 PT0002342 EE0000646 6/30/2003 UPCF(12/99 revised) 0 0