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r' <br /> � oa <br /> UNIFIED PROGRAM CONSOLIDATED FORM ;k'; <br /> TANKSUNDERGROUND STORAGE TANKS-TANK PAGE 2 <br /> f <br /> VI.PIPING CONSTRUCTION(Clack all that <br /> UNDERGROUND PIPING ABOVEGROUND PIPING <br /> SYSTEM TYPE D 1.PRESSURE 0 2.SUCTION 3.GRAVFFY 438. <br /> ❑1.PRESSURE ❑2.SUCTION A:1 3.GRAVITY 459. <br /> CONSTRUCTION/ L SINGLE WALL D 3.LINED TRENCH 0 99.OTHER 460. D I.SINGLE WALL <br /> MANUFACTURER 095.UNKNOWN <br /> C1462 <br /> 2.DOUBLE WALL [195.UNKNOWN [12.DOUBLE WALL ❑99.OTHER <br /> MANUFACTURER MI. MANUFACTURER 463, <br /> BARE STEEL 0 6.FRP COMPATIBLE W/100%METHANOL 0 1.BARE STEEL [16.FRP COMPATIBLE W/100%METHANOL <br /> 2.STAINLESS STEEL [17.GALVANIZED STEEL [12.STAINLESS STEEL [17.GALVANIZED STEEL <br /> D 3.PLASTIC COMPATIBLE WITH CONTENTS 0 95.UNKNOWN [13.PLASTIC COMPATIBLE W/CONTENTS D S.FLEXIBLE(HDPE) 0 99.OTHER <br /> [14.FIBERGLASS D S.FLEXIBLE(HDPE) 0 99.OTHER [14.FIBERGLASS <br /> ❑9.CATHODIC PROTECTION <br /> [15.STEEL W/COATING 0 9.CATHODIC PROTECTION 464. [15.STEEL W/COATMG 0 95.UNKNOWN 463. <br /> VH.PIPING LEAK DETECTION Check ell that tl(p o[dte aodt shalt be subnasal to thebw ,) <br /> UNDERGROUND PIPING ABOVEGROUND PIPING <br /> SINGLE WALL PIPINGt 1 p 1 1/i 466. SINGLE WALL PIPING G 467. <br /> PRESSURIZED PIPING(Check all that apply): u/t/" PRESSURIZED PIPING(Check all that apply): �J0 AJ <br /> ❑1. ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP 01. ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP <br /> SHUT-OFF FOR LEAK,SYSTEM FAILURE,AND SYSTEM DISCONNECTION SHUT OFF FOR LEAK,SYSTEM FAILURE,AND SYSTEM DISCONNECTION <br /> +AUDIBLE AND VISUAL ALARMS. +AUDIBLE AND VISUAL ALARMS. <br /> ❑2. MONTHLY 0.2 GPH TEST 02. MONTHLY 0.2 GPH TEST <br /> []3. ANNUAL INTEGRITY TEST(0.1 GPH) 0 3, ANNUAL INTEGRITY TEST(0.1 GPH) <br /> D 4. DAILY VISUAL CHECK <br /> CONVENTIONAL SUCTION SYSTEMS CONVENTIONAL SUCTION SYSTEMS(Check all that apply) <br /> ❑ <br /> S. DAILY VISUAL MONITORING OF PUMPING SYSTEM+TRIENNIAL PIPING <br /> INTEGRITY TEST(0.1 GPH) [15. DAIS VISUAL MONITORING OF PIPING AND PUMPING SYSTEM <br /> SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): 06. TRIENNIAL INTEGRITY TEST(0.1 GPH) <br /> [17. SELF MONITORING SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): <br /> GRAVITY FLOW [17. SELF MONITORING <br /> [39. BIENNIAL INTEGRITY TEST(0.1 GPH) GRAVITY FLOW(Check all that apply): <br /> 0 S. DAILY VISUAL MONITORING <br /> 09. BIENNWL INTEGRITY TFST(0.I GPH) <br /> SECONDARILY CONTAINED PIPING SECONDARILY CONTAINED PIPING <br /> PRESSURIZED PIPING(Check all that apply): PRESSURIZED PIPING(Check all that apply): <br /> 10. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL 10. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL <br /> ALARMS AND(Check one) ALARMS AND(Check ove) <br /> 0 a.AUTO PUMP SHUT OFF WHEN A LEAK OCCURS D a.AUTO PUMP SHUT OFF WHEN A LEAK OCCURS <br /> 0 b.AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM 0 b.AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM <br /> DISCONNECTION DISCONNECTION <br /> 0c. NO AUTO PUMP SHUT OFF Dc. NO AUTO PUMP SHUT OFF <br /> 0 11. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)WITH FLOW SHUT <br /> OFF OR RESTRICTION D 11.AUTOMATIC LEAK DETECTOR <br /> 0 12. ANNUAL INTEGRITY TEST(RI GPM 0 12.ANNUAL INTEGRITY TEST(RI GPH) <br /> SUCTION/GRAVITY SYSTEM SUCTION/GRAVITY SYSTEM <br /> 013. CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS 013.CONTINUOUS SUMP SENSOR AUDIBLE AND VISUAL ALARMS <br /> EMERGENCY GENERATORS ONLY(Check all that apply) EMERGENCY GENERATORS ONLY(Cheek all that apply) <br /> [314. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF [114. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF <br /> AUDIBLE AND VISUAL ALARMS AUDIBLE AND VISUAL ALARMS <br /> [115. AUTOMATIC LINE LEAK DETECTOR (3.0 GPH TEST) WITHOf1T FLOW 015.AUTOMATIC LINE LEAK DETECTOR 30GPH TEST <br /> SHUT OFF OR RESTRICTION ( ) <br /> 016. ANNUAL INTEGRITY TEST(0.1 GPH) [116.ANNUAL INTEGRITY TEST(0.1 GPH) <br /> 0 17. DAILY VISUAL CHECK 0 17.DAILY VISUAL CHECK <br /> VIH.DISPENSER CONTAINMENT <br /> DISPENSER CONTAINMENT 468. ❑L FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE 04. DAILY VISUAL CHECK 469. <br /> DATEINSTALLED 02. CONTINUOUS DISPENSER PAN SENSOR+AUDIBLE AND VISUAL ALARMS <br /> �� ©W� 03. CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR 05. TRENCH/LINER MONITORING <br /> DISPENSER+AUDIBLE AND VISUAL ALARMS 06. NONE <br /> IX.OWNER/OPERATOR SIGNATURE <br /> Ithat the informitim6 provided herein is bue and accurate to the best of my knowledge. <br /> S TURF OFO 0P DATE, old FA, 470. <br /> AME OFOPE TOR(prim): ,y Y� TITL F OWNER/OPERAATO 4P. <br /> F 17 E3GT I- <br /> Pemut Number(Agency use only) 473. Permit Approved By(Agency use only) 474. Permit Ezpuanov D to(Age use only) 473. <br /> UPCF hwfwm-b(1/99)-3/4 http9/"w.unidocs.org Rev.02/16/00 <br />