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UNIFIED PROGRAM CONSOLIDATED FORM TANKS r UNDERGROUND STORAGE TANKS- TANK PAGE 2 Pae of VI.PIPING CONSTRUCTION Icnect all that ly) UNDERGROUND PIPING ABOVEGROUND PIPING SYSTEM TYPE ❑1.PRESSURE [12.SUCTION 3.GRAVITY 458. ❑1.PRESSURE ❑2.SUCTION PC.GRAVITY 459, CONSTRUCTION/ JW4.SINGLE WALL [13.LINED TRENCH ❑99.OTHER 460. qq.�1�.SINGLE WALL ❑95.UNKNOWN MANUFACTURER P-` 462. [12.DOUBLE WALL [195.UNKNOWN ❑2.DOUBLE WALL ❑99.OTHER MANUFACTURER 461. MANUFACTURER 463. I.BARE STEEL ❑6.FRP COMPATIBLE W/100%METHANOL . ARE STEEL ❑6.FRP COMPATIBLE W/100%METHANOL b`2.STAINLESS STEEL ❑7.GALVANIZED STEEL / 2.STAINLESS STEEL 44 [17.GALVANIZED STEEL [13.PLASTIC COMPATIBLE WITH CONTENTS ❑95.UNKNOWN [13.PLASTIC COMPATIBLE W/CONTENTS ❑S.FLEXIBLE(HDPE) ❑99.OTHER [14.FIBERGLASS [18.FLEXIBLE(HDPE) ❑99.OTHER ❑4.FIBERGLASS Cl 9.CATHODIC PROTECTION ❑5.STEEL W/COATING ❑9.CATHODIC PROTECTION 469. ❑5.STEEL W/COATING [195.UNKNOWN 465. VIL PIPING LEAK DETECCION(Cneck all nut ) Ad 'tion oOhe moNtmirw shall be abmhtdmthe bal .) UNDERGROUND PIPING ABOVEGROUND PIPING SINGLE WALL PIPING 4%. 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 [31. ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH 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. [12. MONTHLY 0.2 GPH TEST [12. MONTHLY 0.2 GPH TEST [33. ANNUAL INTEGRITY TEST(0.1 GPH) [13. ANNUAL INTEGRITY TEST(0.1 GPH) 04. DAILY VISUAL CHECK CONVENTIONAL SUCTION SYSTEMS CONVENTIONAL SUCTION SYSTEMS(Check all that apply) [15. DAILY VISUAL MONITORING OF PUMPING SYSTEM+TRIENNIAL PIPING [15. DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM INTEGRITY TEST(0.1 GPH) SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): [16. TRIENNIAL INTEGRITY TEST(0.1 GPH) ❑7. SELF MONITORING SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): GRAVITY FLOW [17. SELF MONITORING C39. BIENNIAL INTEGRITY TEST(0.1 GPH) GRAVITY FLOW(Check all that apply): [18. DAILY VISUAL MONITORING [19. BIENNIAL INTEGRITY TEST(0.1 GPH) SECONDARILY CONTAINED PIPING SECONDARILY CONTAINED PIPING PRESSURIZED PIPING(Check a0 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(Check me) ALARMS AND(Check one) ❑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 Oc. NO AUTO PUMP SHUT OFF �c. NO AUTO PUMP SHUTOFF ❑11. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)WITH FLOW SHUT El II AUTOMATIC LEAK DETECTOR OFF OR RESTRICTION ❑12. ANNUAL INTEGRITY TEST(0.1 GPH) [312. ANNUAL INTEGRITY TEST(0.1 GPH) SUCTION/GRAVITY SYSTEM SUCTION/GRAVITY SYSTEM [113, 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 014. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF AUDIBLE AND VISUAL ALARMS AUDIBLE AND VISUAL ALARMS [115. AUTOMATIC LINE LEAK DETECTOR (3.0 GPH TEST) WITHOUT FLOW SHUT OFF OR RESTRICTION MI5.AUTOMATIC LE LEAK DETECTOR(3.0 GPH TEST) [316. ANNUAL INTEGRITY TEST(0.1 GPH) [116.ANNUAL INTEGRITY TEST(0.1 GPH) [317. DAILY VISUAL CHECK ❑17.DAILY VISUAL CHECK VIII.DISPENSER CONTAINMENT DISPENSER CONTAINMENT 468. ❑l. FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE ❑4. DAILY VISUAL CHECK 469, DATE INSTALLED C]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. SIGNATURE OF OWN O E ATOR DATE: 470, 7 NAME OF OWNER/pPERATOR(print): TITLE OF OWNER/OPERATOR: fin' I ` '%- cera �2 cmc�e Cp�, Pro i�. Permit Number(Agency use only) 473. Pmmh Approved By(Agency use only) 474. Permit Expiration Dare(Agency use only) 475. UPCF hwfwm-b(1/99)-3/4 hup://www.unidocs.org Rev.02/16/00