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1 UNIFIED PROGRAM CONSOLIDATED FORM TANK: TA0515579 <br /> a PRM: PROS16874 <br /> FAC.: FADOD2463 <br /> UNDERGROUND STORAGE TANKS-TANK PAGE 2 <br /> V1.PIPING CONS=UCTION(O %NlwtwI,) Pnu]ors <br /> UNDERGROUND PIPING ABOVEGROUND PIPING <br /> SYSTEMTYPE ❑ 1,PRESSURE ❑2.SUCTION ❑3.GRAVITY 451 ❑ L PRESSURE ❑2.SUCTION ❑3,GRAVITY i59 <br /> CONSTRUCUOM ❑I.SINGLE WALL 1-13.LINED TRENCH ❑99.OTHER 460 ❑ 1,SINGLE WALL ❑95.UNKNOWN adz <br /> ❑2.1)OUBLEWAL1, ❑95.U9IONOWN El DOUBLE WALL ❑W-OTHER <br /> MANUFACTURER 461 MANUFACTURER 463 <br /> ❑ LEASE STEEL ❑6.FRP.COMPATTBLE.v IMwa4ErRANOL ❑ I,RARE STEEL ❑6.PRP COMPATIBLE m I=meTHANm <br /> [12.STAINLESS STEEL ❑ 7.GALVANrzED STEEL ❑2.STAINLIsss STEEL ❑7.GALVANIZED STEEL <br /> ❑PLASTIC COMPATIBLE W/CONTENTS ❑95.UNKNOWN ❑PLASTIC COMPATIBLE W/CONTENTS ❑S5.UNKNOWN <br /> ❑4.PIBEROLASS ❑ S.PLEKIBLE(HDPE) ❑RR OTHER ❑4.FIBERGLASS ❑R FLENIBLE(IMPE) ❑SR OTHER <br /> ❑ S.STEEL W/COATING ❑9.CATHODICPHOTECTIDN 464 ❑S.STEEL W/COATING ❑ 9.CATHODIC PROTECTION 465 <br /> / VII.PIPING LEAK DY19CTION nockell N 1pay)(AI vm,,Umofthe 1110Nbf1Yyp1011e111 than M30brciW.l kcalatmeyj <br /> UNDERGROUND PIPMG ABOYEOROUND PIPING <br /> SINGLEWALL PIPING 466 SINGLE WAIL PIPING 40 <br /> PRESSURIZED PIPING(Check all Uml apply): PRESSURIZED PIPING(Check au that apply): <br /> ❑ I.ELECTRONIC LINE LEAK DETECTOR3.0 GPH TESTw�yAUTO PUMP SHUT OFF ❑ I.ELECTRONIC LINE LEAK DETECTOR 3.0.GPH TESTRIIHAUTO PUMP SHUT OFF <br /> FOR LEAK SYSTBMFAILUEE,AND SYSTEM DISCONNECTION+AUDIBLE AND FOR LEAK.SYSTEM FAILURE,AM)SYSTEM DISCONNECTION+AUDIBLE AND <br /> VISUAL ALARMS. vISUALALARMs. <br /> ❑ I MONTHLY 02 DPH TEST ❑2.MONTHLY 0.2 GPH TEST ❑3.ANNUAL INTEGRITY TEST(MI OPH) <br /> 3.ANNUALINTEGRITYTEST(0.1 GPI!) <br /> ❑4.DAILY VISUAL CHECK <br /> CONVENTIONAL SUCTION SYSTEMS CONVENTIONAL SUCTION SYSTEMS(Cheek all ehae apply) <br /> ❑S.DAILYV13UALMOMTOXNOOFPIIWING SYSTEM+TRIENNIEAL PTING ❑3.DAILYVISUAL MONITORINUOPPIPNOAND PUMPING SYSTEM <br /> INTEGRITY TEST(al OPfO <br /> ❑4TRIENNUL DTTEGRITY TEST(0,1 GPH) <br /> SAYE SUCTIONSYSTEMS(NO VALUES IN RELOW GROUNDPIPING)a SAFE SUCTION SYSTEMS(NO VALUES IN BELOW GROINDPIPING)e <br /> ❑7.SELFMONITORNO <br /> ❑7.SELF MONITORING <br /> GRAVITY YLow <br /> ❑9.BIENNIAL INTEGRITY TEST(0.1)GPH GRAVITY FLOW(Check all that apply): <br /> ❑ 8.DAILYVISUAL MONITORING <br /> ❑9,BtEMJL1L INTEGRITY TEST(0.1)GPH <br /> SECONDARILY CONTAINED PIPING SECONDARILY CONTAINED PIPING <br /> PRESSURIZED PIPING(Check all that apnN); PRESSUETZ"PIPING(Check Al that apply): <br /> 410,CONTINUOUS TURIUME SUMP SENSOR WITH AUDIBLE AND VISUAL 10,CONTINUOUS TURBINE SUMP SENSORWITH AUDIBLE AM VISUAL <br /> ALARMSAND(oack.) ALARMSAND(Oee a.) <br /> ❑ <br /> R.AUTO PUMP SHUT OFF WHEN A LEAK OCCURS ❑s.AUTO PUMP SHUT OFF WHEN A LEAK OCCURS <br /> ❑b.AUTOPUMPSHUTOPPFORLEAKS,SYSTEMFMLUREANDS=S ❑b.AUTO PUMP SHUT OFF FORURARS,SYSTEM FAILURE AND SYSTEM <br /> DISCONNECTION DISCONNECTION <br /> ❑ e,NOAUTOPUMP SHUT OFF ❑a NOAUTO PUMP SHUT OFF <br /> ❑ II,AUTOMATICLNELEARDH)P.CTOR(3,QGPHTEST)W P10WSHUFOPPOR <br /> RESTRICTION 11.AUTOMATIC LEAK DETECTOR <br /> ❑ 12.ANNUAL NTEORITYTEST(O.I OPH) ❑ 12.ANNUAL INTEORITYTEST(O.I OPH) <br /> SUCTRIN/GRAYITYBYSTEM SULTION/GRAVITY SYSTEEI <br /> ❑ 13,CONTINUOUS SUMP SENSOR+AWHILE AND VISUAL ALARMS ❑ 13.CONTINUOUS SUMP SENSOR AUDIBLE AND.VISUAL ALARMS <br /> EMERGENCY GENERATORS ONLY(Cheek ell ma apply) EMERGENCY GENERATORS ONLY(am;al ma apply) <br /> ❑ 14.CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF• ❑ 14..CONTINUOUS SUMP SENSORyYtrflgUTAUTOPUMPSHUTOFP- <br /> AUDIBLEAND VISUAL ALARMS AUDIBLE AND VISUAL ALARMS <br /> ❑ 15.AUTOM nCLMELP DETECTOR(3.OGPH'TMT)WITHOITT FLOW ❑ 15.AUTOMATIC LME LEAK•DRTECTOR(3,0 OPH TEST)WITHOUT FLOW <br /> ESUTOFFORRBSTRICTION SHUT OFF ORRESTRICTION <br /> ❑ 16.ANNUAL INMORITYTBST(o.l GPH) ❑ 16.ANNUAL NTEORITY TEST(0.I OPH) <br /> ❑ 17.DAH.YVISUALCHECK ❑ 11.DAILYVISUAL CHECK <br /> VRI.DISPENSER CONTAINMENT <br /> DISPENSER CONTAINMENT ❑ 1.PwATMECHANISMTHATSHUTSOpp SHeARVALVE n4.DAILYVISUAL CHECK <br /> DATE INSTALLED 1� <br /> 461 ❑I CONTINUOUS DISPENSER PAN SENSOR+AUDIBLE AND VISUALALARMS ❑5,TRENCH LNER/MONITORING <br /> [13.CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR ❑6.NONE <br /> DISPENSER+AUDIBLE AND VISUAL ALARMS 469 <br /> IX,OVPXBRIOPERATOR SIGNATURE <br /> Ianiywalwclnf ales Pmvtha naanlewce awe hnta e <br /> SIGNATURE OF OWNPR/OPERATOR I a PATE 470 <br /> NAME OF OWN6R/OPE R(print) TITLE OFOWN6R/OP6RATOR <br /> ql /9 472 <br /> PmNl Nanher(Pa l4wlutemty) 413 Pmnh AppimW(Pa heel ute4aly) 474 J petmlt aPrtlenO c(F l4mlax 4aly) 473 <br /> PT0002455 PE0000817 6/30/2007 12:00:OOAM <br /> UPCF(12/99 revised) <br /> fi00 'd 80108S860ZI 'ON %Vd 'AM SM 903 0003 WV 0690 NOULOOZ/6I/M <br />