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r %II&J7 r UNIFIED PROGRAM CONSOLIDATED FORM v� TANKS r� UNDERGROUND STORAGE TANKS- TANK PAGE 2 P of VL PIPING CONSTRUCTION Cheek Yldm UNDERGROUND PIPING ABOVEGROUND PIPING SYSTEM TYPE ❑1.PRESSURE ❑2.SUCTION 3.GRAVITY 458. ❑1.PRESSURE ❑2.SUCTION 7O3.GRAVITY 939. CONSTRUCTION/ .SINGLE WALL ❑3.LINED TRENCH ❑99.OTHER 960. ❑1.SINGLE WALL ❑95.UNKNOWN 462 MANUFACTURER ❑z.DOUBLE WALL ❑95.UNKNOWN ❑x.DOUBLE WALL ❑99.OTHER MANUFACTURER 461. 1 MANUFACTURER 463, BARE STEEL ❑6.FRP COMPATIBLE W/100%METHANOL [11.BARE STEEL ❑6.FRP COMPATIBLE W/100%METHANOL 2.STAINLESS STEEL ❑7.GALVANIZFD STEEL ❑2.STAINLESS STEEL ❑7.GALVANIZED STEEL ❑3.PLASTIC COMPATIBLE WITH CONTENTS ❑95.UNKNOWN ❑3.PLASTIC COMPATIBLE W/CONTENTS ❑S.FLEXIBLE(HDPE) ❑99.OTHER ❑4.FIBERGLASS ❑S.FLEXIBLE(HOPE) O 99.OTHER ❑4.FIBERGLASS ❑9.CATHODIC PROTECTION ❑5.STEEL W/COATING ❑9.CATHODIC PROTECTION 464. [15.STEEL W/COATING ❑95.UNKNOWN 465. VI.PIPING LEAK DETECITONOnck all that A ;,a after aceitoxcli prespeare.dall be wbdited m the beat UNDERGROUND PIPING ABOVEGROUND PIPING SINGLE WALL PIPING l I y 1)/ � 466. SINGLE WALL PIPING �(JD/J G 467. PRESSURIZED PIPING(Check all that appy): [/l'V 1�-�v PRESSURIZED PIPING(Check all that apply): ❑1. EL MONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP [31. ELECTRONIC LINE LEAK DETECTOR 3.0 GPM 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. ❑2. MONTHLY 0.2 GPH TEST ❑2. MONTHLY 0.2 GPH TEST [13. 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 appy) ❑5. DAILY VISUAL MONITORING OF PUMPING SYSTEM+TRIENNIAL PIPING C15. DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM INTEGRITY TEST(0.1 GPH) SAFE SUCTION SYSTEMS MO VALVES IN BELOW GROUND PIPING): [16. TRIENNIAL INTEGRITY TEST(0.1 GPH) [17. SELF MONITORING SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): GRAVITY FLOW E3 7. SELF MONITORING [19. BIENNIAL INTEGRITY TEST(0.1 GPH) GRAVITY FLOW(Check all that apply): ❑S. 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(Clack ow) ALARMS AND(Check ore) ❑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 SHITE OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM DISCONNECTION DISCONNECTION [3c. NO AUTO PUMP SHUT OFF [3c. NO AUTO PUMP SHUTOFF ❑11. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)WITH FLOW SHUT [3 11 AUTOMATIC LEAK DETECTOR OFF OR RESTRICTION ❑12. ANNUAL INTEGRITY TEST(0.1 GPH) ❑12. ANNUAL INTEGRITY TEST(0.1 GPH) SUCTION/GRAVITY SYSTEM SUCTION/GRAVITY SYSTEM [3 13. CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS 013.CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS EMERGENCY GENERATORS ONLY(Cheek all that apply) EMERGENCY GENERATORS ONLY(Check all that apply) [114. CONTINUOUS SUMP SENSORRW HO171'AUTO PUMP SHUT OFF ❑14.CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF AUDIBLE AND VISUAL ALARMS AUDIBLE AND VISUAL ALARMS [115. AUTOMATIC LME LEAK DETECTOR (3.0 GPH TEST) WITHOUT FLOW 0 I5.AUTOMATIC LME LEAK DETECTOR(3.0 GPH TEST) SHUT OFF OR RESTRICTION ❑l6. ANNUAL INTEGRITY TEST(0.1 GPH) [116. ANNUAL INTEGRITY TEST(0.1 GPH) [117. DAILY VISUAL CHECK [117.DAILY VISUAL CHECK VII-DISPENSER CONTAINMENT DISPENSER CONTAINMENT 468. []1. FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE [14. DAILY VISUAL CHECK 469. DATE INSTALLED [32. CONTINUOUS DISPENSER PAN SENSOR+AUDIBLE AND VISUAL ALARMS ❑5. TRENCH/LINER MONITORING y J [13. CONTINUOUS DISPENSER PAN SENSOR w= AUTO SHUT OFF FOR DISPENSER+AUDIBLE AND VISUAL ALARMS ❑6. NONE IX.OWNER/OPERATOR SIGNATURE I c ' m that the infora' provided herein is true and accurate to the best of my knowledge. TORE UFO 0P DATE: �/d �A, 470. SrV 'ffAME OF OWh&0PEqTOR(prm0: 4M, YV\ TAT02 UNE Permit Number(Agency use only) 473. Permit Approved By(Agency use only) 474. 1 Permit Expiration D to(Age ux avly) 475. UPCF hwfwre-b(1/99)-3/4 http://www.unidoo.org Rev.02/16/00