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UNIFIED PROGRAM CONSOLIDATED F ORM TANKS UNDERGROUND STORAGE TANKS -TANK PAGE 2 of VI.PIPING CONSTRUCTION(Check ad that appy) UNDERGROUND PIPING ABOVEGROUND PIPING SYSTEM TYPE PRESSURE ❑ 2. SUCTION ❑ 3. GRAVITY ❑ 1. PRESSURE ❑ 2. SUCTION ❑ 3. GRAVITY CONSTRUCTION/ ❑ 1. SINGLE WALL ❑ 3. LINED TRENCH ❑99. OTHER ❑ 1. SINGLE WALL ❑95; UNKNOWN MANUFACTURER DOUBLE WALL ❑95. UNKNOWN ❑ 2. DOUBLE WALL ❑99. OTHER MANUFACTURER MANUFACTURER ❑ 1.BARE STEEL ❑ e. FRP COMPATIBLE W/100%METHANOL ❑ 1. BARE STEEL ❑ S. FRPCOMPATIBLEWI 100%METHANOL MATERIALS AND ❑ 2_ STAINLESS STEEL ❑ 7.GALVANIZED STEEL ❑ 2. STAINLESS STEEL ❑ 7. GALVANIZED STEEL CORROSION PROTECTION ❑ 3. PLASTIC COMPATIBLE WITH CONTENTS 11 95. UNKNOWN ❑ 3. PLASTIC COMPATIBLE WITH CONTENTS ❑ B. FLEXIBLE(NOPE) ❑99. OTHER 4. FIBERGLASS ❑ S. FLEXIBLE(HDPE) 1199. OTHER ❑ 4 FIBERGLASS ❑ 9. CATHODIC PROTECTION ❑ 5. STEEL WI COATING ❑ 9. CATHODIC PROTECTION ❑ 5. STEEL W1 COATI NG 095. UNKNOWN WL PIPING LEAK DETECTION(Check all that appy) UNDERGROUND PIPING ABOVEGROUND PIPING SINGLE WALL PIPING SINGLE WALL PIPING PRESSURIZED PIPING(Cheat ed that appy): PRESSURIZED PIPING(Check ad that appy): ❑ 1. ELECTRONIC UNE LEAK DETECTOR 3.0 GPM TEST VATH AUTO PUMP SHUT OFF FOR ❑ 1. ELECTRONIC LINE LEAK DETECTOR 3.0 GPM TEST WITH AUTO PUMP SHUT OFF FOR LEAK, LEAK,SYSTEM FAILURE,AND SYSTEM DISCONNECTION-AUDI BLE AND VISUAL SYSTEM FAILURE,AND SYSTEM DISCONNECTION+-AUDIBLE AND VISUAL ALARMS ALARMS ❑ ❑ 2MONTHLY 2. MONTHLY 0.2 GPH TEST . 0 2 GPT TEST ❑ 3. ANNUAL INTEGRITY TEST(0.1 GPM) ❑ 3. ANNUALINTEGRITYC ITYTEST(0.1 GPM) 11 <, DAILY VISUAL CHECK CONVENTIONAL SUCTION SYSTEMS: CONVENTIONAL SUCTION SYSTEMS(Check all that appy): ❑ 5. DAILY VISUAL MONITORING OF PUMPING SYSTEM+TRIENNIAL PIPING INTEGRITY ❑ 5. DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM TEST(0.1 GPM) ❑ S. TRIENNIAL INTEGRITY TEST(0.1 GPM) SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): ❑ 7. SELF MONITORING ❑ 7. SELF MONITORING GRAVITY FLOW GRAVITY FLOW(Check all that apply): ❑ 9. BIENNIAL INTEGRITY TEST IDI GPM) ❑ S. DAILY VISUAL MONITORING ❑ 9. BIENNIAL INTEGRITY TEST IDA GPT) SECONDARILY CONTAINED PIPING SECONDARILY CONTAINED PIPING PRESSURIZED PIPING(Check all that apply) PRESSURIZED PIPING(Chad*ed that appy): 10. CONTINUOUS TURBINE SUMP,SENSOR WITH AUDIBLE AND VISUAL ALARMS AND(Check one) 10.CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL ALARMS AND(chook one) ❑ e. AUTO PUMP SHUT OFF WHEN A LEAK OCCURS ❑ a. AUTO PUMP SHUT OFF MEN A LEAK OCCURS tRb. AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM ❑ b. AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM DISCONNECTION DISCONNECTION ❑ c. NOAUTO PUMP SHUT OFF ❑ c. NOAUTO PUMP SHUTOFF 11. AUTOMATIC LINE LEAK DETECTOR(3.0 GPM TEST)`NTH FLOW SHUT OFF OR ❑ 11. AUTOMATIC LEAK DETECTOR RESTRICTION ❑ 12. ANNUAL INTEGRITY TEST 10.1 GPM) ❑ 12. ANNUAL INTEGRITY TEST IDA GPM) SUCTIONGRAVITY SYSTEM: SUCTIONIGRAVITY SYSTEM: ❑ 13. CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS ❑ 13. CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUALALARMS EMERGENCY GENERATORS ONLY(Check all that appy) EMERGENCY GENERATORS ONLY(Check ad had apply) ❑ 14. CONTINUOUS SUMP SENSOR WTHOUTAUTO PUMP SHUT OFF.AUDIBLE AND ❑ 14. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF+AUDIBLE AND VISUAL VISUALALARMS ALARMS ❑ 15. AUTOMATIC LINE LEAK DETECTOR(3.0 GPM TEST)WITHOUT FLOW SHUT OFF OR ❑ 15. AUTOMATIC LINE LEAK DETECTOR(3.0 GPM TEST) RESTRICTION - ❑ 16.ANNUAL INTEGRITY TEST(DA GPM) ❑ 16. ANNUAL INTEGRITY TEST(0.1 GPH) ❑ IT DAILY VISUAL CHECK ❑ 17. DAILY VISUAL CHECK VIII.DISPENSER CONTAINMENT DISPENSER CONTAINMENT ❑ 1. FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE ❑ 4. DAILY VISUAL CHECK DATE INSTALLED ❑ 2. CONTINUOUS DISPENSER PAN SENSOR-AUDIBLE AND VISUAL ALARMS ❑ 5. TRENCH LINER/MONITORING . CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR DISPENSER+AUDIBLE AND VISUAL ALARMS ❑ 6. NONE IX.OWNER/OPERATOR SIGNATURE I csniy that in rmatio pmvieed herein is tme an o a best of my*naN edge. SIGNATOR OF E PERATOR GATE alg, D NAME OF OPNE O ERA R(paha) T TITLE OF O - P ATOR Penntt Number(For local we only) Permit Approved(For/me/use o Petmh Eapirabon Date(Forlodl u»oM1g CUPAFORM(4199) 0 • Formerly SWRC13 Form B