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a•IY IJNIFtaD PROGRAM CON3OLtDAT[o FORM UNDERGROUND STORAGE TANKS - TANK PAGE 2 TANKS VI,PIPING CONSTRUCTION{Check aI toot aWAy) UNDERGROUND PIPING ABOVEGROUNQ PIPING 4 SYSTEM TYPE 1. PRESSURE ❑ 2. SUCTION ❑ 3. GRAVITY 456 ❑ 1, PRESSURE ❑ 2. SUCTION ❑ 7. GRAVITY 459 CONSTRUCTION/El 1. SINGLE WALL ❑ 3. LINED TR€NCH -199 OTHER 460 ❑ 1. SINGLE WALL ❑95, UNKNOWN MANUFACTURER 2. DOUBLE WALL ❑95. UNKNOWN 462 ❑ 2. DOUBLE watt ❑99. OTHER MANUFACTURER 461 MANUFACTURER 463 ❑ 1.BARE STEEL { 6. FRP COMPATIBLE W/I00%METHANOL ❑ 1. BARE STEEL ❑ S. FRP COMPATIBLE W/'DO%METHANOL MATERIALS AND ❑ 2, STAINLESS STEEL ❑ T. GALVANIZED STEEL El 2. STAINLESS STEEL El 7. GALVANIZED STEEL CORROSION PROTECTION ❑ 3. PLASTIC COMPATIBLE WITH CONTENTS ❑95. UNKNOWN ❑ 3. PLASTIC COMPATIBLE WITH CONTENTS ❑ 6. FLEXIBLE(HDPE) ❑99. OTHER ❑ 4. FIBERGLASS ❑ B. FLEXIBLE(HDPE) 1399. OTHER El 4. FIBERGLASS ❑ 9, CATHODIC PROTECTION ❑ 5. STEEL Wl COATING ❑ 9. CATHODIC PROTECTION 464 ❑ 5, STEEL W1 COATING ❑95. UNKNOWN 465 Ill.PIPING LEAK DETECTION{Checka#fhatapray) UNDERGROUND PIPING ABOVEGROUND PIPING SINGLE WALL PIPING 466 PRESSURIZED PIPING(Check all that eppSINOLE WALL PIPINGPy); PRESSURIZED PIPING(Check JW that apply): 467 ❑ I. ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP SHUT OFF FOR ❑ 1. ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP SHUT OFF FOR LEAK LEAK,SYSTEM FAILURE,AND SYSTEM DISCONNECTION+AUDIBLE AND VISUAL SYSTEM FAILURE,AND SYSTEM DISCONNECTION+AUDIBLE AND VISUAL ALARMS ALARMS ❑ 2, MONTHLY 0.2 GPH TEST ❑ 2. MONTHLY 0.2 GPH TEST ❑ ❑ 3. ANNUAL INTEGRITY TEST(0.1 GPH 1 3. ANNUAL INTEGRfFY TEST(0.1 GPH) ) ❑ 4. DAILY VISUAL CHECK CONVENTIONAL SUCTION SYSTEMS: CONVENTIONAL SUCTION SYSTEMS(Check a&that appy): I ❑ S. DAILY VISUAL MONITORING OF PUMPING SYSTEM+TRIENNIAL PIPING INTEGRITY ❑ 5. DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM J h TEST{0.1 GPH) ❑ 6. TRIENNIAL INTEGRITY TEST(0.1 GPH) I SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): C1 TSAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): .. SELF MONITORING ❑ 7. SELF MONITORING GRAVITY FLOW: GRAVITY FLOW(Chalk a#that appy): ❑ 9. BIENNIAL INTEGRITY TEST(0.1 GPH) ❑ S. DAILY VISUAL MONFTOR114G jy ❑ 9. BIE N N IAL INTEGRITY TEST(0.1 GPH) ! I SECONDARILY CONTAINED PIPING SECONDARILY CONTAINED PIPING PRESSURIZED PIPING;Check all that apply). PRESSURIZED PIPING(Check 89 that apply). I 10. CONTINUOUS TURBINE SUMP SENSOR WITH AUDFBLE AND VISUAL ALARMS AND 10. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL ALARMS AND(cmeck (Check one) a. AUTO PUMP SHUT OFF WHEN A LEAK OCCURS one) [ AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM Cl a. AUTO PUMP SHUT OFF WHEN A LEAK OCCURS DISCONNECTION ❑ 13 AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM DISCONNECTION ❑ c. NO AUTO PUMP SHUT OFF 11. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)WITH FLOW SHUT OFF OR ❑ C. NO AUTO PUMP SHUT OFF !I RESTRICTION j I❑ 12. ANNUAL INTEGRITY TEST(p,l GPH) N/A C1 11. AUTOMATIC LEAK DETECTOR ❑ Q. ANNUAL INTEGRITY TEST(0.1 GPH) I CTION/GRAVITY SYSTEM: 12 13. CCNTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS SUCT)OWGRAVITY SYSTEM:. El 11 CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS II EMERGENCY GENERATORS ONLY(Check a6 that Apply) i❑ 14. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF+AUDIBLE AND EMERGENCY GENERATORS ONLY(Check aA that apply) VISUAL ALARMS ❑ 14, CONTINUOUS SUMP SENSOR WET AUTO PUMP SHUT OFF-AUDIBLE AND VISUAL ❑ 15. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)WITHOU FLOW SHUT Q€F OR ALARMS RESTRICTION ❑ 15. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST) ❑ 16. ANNUAL INTEGRITY TEST 40.1 GPHI ❑ 17. DAILY VISUAL CHECK ❑ 16. ANNUAL INTEGRITY TEST(0.1 GPH) ❑ 17. DAILY VISUAL CHECK VIII.DISPENSER CONTAINMENT otSPENSER CONTAINMENT ❑ 1. FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE ❑ 4. DAILY VISUAL CHECK DATE INSTALLED 466 IN 2- CONTINUOUS DISPENSER PAN SENSOR-AUDIBLE AND VISUAL ALARMS ❑ 5. TRENCH LINER/MONITORING Cl 3. CONTINUOUS DISPENSER PAN SENSORMtT}AUTO SHUT OFF FOR DISPENSER+AUDIBLE AND VISUAL ALARMS ❑ 6. NONE 469 I IX.OWNERIOPERATOR SIGNATURE I Certify khat the lnfmmatlon provided herein}s Irue and accurate 10 Lhe 13831 Of my kn vAedge. SIGNATURE OF OWNER/OPERATOR DATE 470 fNAME OF OWNERIOPERATOR(pont) 471 TITLE OF OWNER)OPERATOR 472 Tim Juif Agent for Owner Pemv!Num138r(For beau wa only) 473 Perml Approved(For bca!uss 000y) 474 Parmt Expiration Data(For local v»only) 4T5 UPCF(1199) Formerly SWRC13 Form B