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UNIFIED PROGRAM CONSOLIDATED FORM TANKS UNDERGROUND STORAGE TANKS- TANK PAGE 2 Page of- Vt.PIPING.CONSTRiYhTI15$b' UNDERGROUND PIPING ABOVEGROUND PIPING SYSTEM TYPE ❑1.PRESSURE CS2.SUCTION [13.GRAVITY 4A ❑I.PRESSURE ®.2.SUCTION 0 3.GRAVITY 459. CONSTRUCTION/ 1.SINGLE WALL 0 3.LINED TRENCH 0 99.OTHER 460. J&1.SINGLE WALL 0 95.UNKNOWN 462 MANUFACTURER 0 2.DOUBLE WALL 0 95.UNKNOWN 0 2.DOUBLE WALL 0 99.OTHER MANUFACTURER 461. MANUFACTURER 463. 1.BARE STEEL. [16.FRP COMPATIBLE W/100%METHANOL 1.BARE STEEL 0 6.FEE,COMPATIBLE W/100%METHANOL 0 2.STAINLESS STEEL 0 7.GALVANIZED STEEL ❑2.STAINLESS STEEL [17.GALVAN®STEEL [13.PLASTIC COMPATIBLE WITH CONTENTS 0 95.UNKNOWN 0 3.PLASTIC COMPATIBLE W/CONTENTS 0 8.EIMOBLE(HOPE) 0 99.OTHER 0 4.FIBERGLASS 0 8.FLEXIBLE(HOPE) 0 99.OTHER 0 4.FIBERGLASS 0 9.CATHODIC PROTECTION ❑ S.STEEL W/COATING 0 9.CATHODIC PROTECTION 461. 0 5 STEEL W/COATING [195.UNKNOWN 465' +. . :'.- -VIE'EIPEYGi�AIC UETECTION(LbakaB ". ,.... ': ostmmoMo' ..� ••,.ehal6hitiofimniedtowewizt uz,,.,:;�. .,..'y`.;.: UNDERGROUND PIPING ABOVEGROUND PIPING SINGLE WALL PIPING 466. SINGLE WALL PIPING 467. PRESSURIZED PIPING(Clack all that apply): PRESSURIZED PIPING(Check ad that apply): 01. ELECTRONIC 124B LEAK DETECTOR 3.0 GPH TESTI, H AUTO PUMP 0 1. ELECTRONIC LINE LEAKDETECTOR 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. 02. MONTHLY 0.2 GPH TEST 02. MONTHLY 02 GPH TEST [13. ANNUAL INTEGRITY TEST RE]GPH) [13. ANNUAL INTEGRITY TEST(0.1 GPIs) N 4. DAILY VISUAL CHECK CONVENTIONAL SUCTION SYSTEMS CONVENTIONAL SUCTION SYSTEMS(Cheek all that apply) 0 5. DAILY VISUAL MONITORING OF PUMPING SYSTEM+TRIENNIAL PIPING 0 5. DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM INTEGRITY TEST(0.1 GPH) SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): ❑6. TRIENNIAL INTEGRITY TEST(0.1 GPH) 0 7, SELF MONITORING SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): GRAVITY FLOW [17. SELF MONITORING 09. BIENNIAL INTEGRITY TEST(0-1 GPM GRAVITY FLOW(Check all that apply): 0 S. DAILY VISUAL MONITORING d 09. BIENNIAL INTEGRITY TEST(0.1 GPH) SECONDARILY CONTAINED PIPING SECONDARILY CONTAINED PIPING PRESSURIZED PIPING(Chale 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(Check ane) ALARMS AND(Chock one) 0 a_AUTO PUMP SHUT OFF WHEN A LEAK OCCURS 0 a AUTO POMP SHUT OFF WHEN A LEAK OCCURS 0 b.AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM ❑b.AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM DISCONNECTION DISCONNECTION Cc. NO AUTO PUMP SHUT OFF De. NO AUTO PUMP SHUT OFF ❑ 11. AUTOMATIC LUNE LEAK DETECTOR(3.0 GPH TEST)WITH FLOW SHUT 0 11. AUTOMATIC LEAK DETECTOR OFF OR RESTRICTION ❑ 12 ANNUAL INTEGRITY TEST(0.1 GPH) 0 12 ANNUAL INTEGRITY TEST(0.1 GPH) SUCTION/GRAVITY SYSTEM SUCTIONIGRAVITY SYSTEM 013. CONTINUOUS SUMP SENSOR,AUDIBLE AND VISUAL ALARMS 013.CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS EMERGENCY GENERATORS ONLY(Cheek a0 that apply) EMERGENCY GENERATORS ONLY(Chock all that apply) [114. CONTINUOUS SUMP SENSOR WITH011T AUTO PUMP SNIT OFF 0 14.CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF AUDIBLE AND VISUAL ALARMS 015. AUTOMATIC LINE LEAK DETECTOR (3.0 GPH TEST) wrErjouT FLOW 015.AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST) SHUT OFF OR RESTRICTION 0 16. ANNUAL INTEGRITY TEST(0.1 GPIs) ❑16.ANNUAL INTEGRITY TEST AI GPM) 0 17. DAILY VISUAL CHECK 0 17.DAILY VISUAL CHECK YI6 DISPENSFR.CONTArNMENT:. DISPENSER CONTAINMENT 468. 01. FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE 04. DAILYVISUALCHECK 469. DATE INSTALLED 02. CONTINUOUS DISPENSER PAN SENSOR+AUDIBLE AND VISUAL ALARMS 05. TRENCH/LINER MONITORING 03. CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR a6. NONE DISPENSER,AUDIBLE AND VISUAL ALARMS IX...OWNER/OPERATOR.SIGYArA'S3RL. 1 cetnfy that the information provided herein is true slid=mate to the best of my knowledge. 4NAMEOFjOiDPERATOR(print)- NER/OP DATE. iOMaY O Z qo. �J 47x. TITLE OF OWNERIOPERkOR.- ff0fCr4-y OW nC/' d Gnc (?jpwma/1 Permit Number(Agency use only) 473. Fermi[Approved By(Agency we only) 474. 1 Permit Expiration Data(Agancy use only) 495. UPCF hwfWm-b(1/99)-314 http://Www.unidoo.org Rev.U7J16/BO • i