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k JIv D PROGRAM CONSOLIDATED �•/ ""� TANKS UNDERGROUND STORAGE TANKS - TANK PAGE 2 Pae of VL PIPING CONSTRUCTION(Check as that apply) UNDERGROUND PIPING ABOVEGROUND PIPING SYSTEM TYPE M L PRESSURE 0 2.SUCTION 0 3.GRAVITY 458. 0 1.PRESSURE 0 2.SUCTION 0 3.GRAVITY 459. CONSTRUCTION/ 0 L SINGLE WALL 0 3.LINED TRENCH 0 99,OTHER 460, 0 1.SINGLE WALL 0 95.UNKNOWN 462. MANUFACTURER 0 2 DOUBLE WALL 0 95.UNKNOWN 0 2.DOUBLE WALL 0 99.OTHER MANUFACTURER A.O. Smith 461. MANUFACTURER 4(53 0 1.BARE STEEL 0 6.FRP COMPATIBLE W/100%METHANOL ❑1.BARE STEEL 0 6.FRP COMPATIBLE W/100%METHANOL 0 2.STAINLESS STEEL 0 7.GALVANIZED STEEL 0 2.STAINLESS STEEL 0 7.GALVANIZED STEEL 0 3.PLASTIC COMPATIBLE WITH CONTENTS 0 95.UNKNOWN O 3.PLASTIC COMPATIBLE W/CONTENTS 0 S.FLEXIBLE(HDPE) 0 99.OTHER [14.FIBERGLASS 0 8.FLEXIBLE(HDPE) 0 99,OTHER 0 4.FIBERGLASS 0 9.CATHODIC PROTECTION 0 5.STEEL W/COATING 0 9.CATHODIC PROTECTION 464. [15.STEEL W/COATING 0 95.UNKNOWN 465. VIL PIPING LEAK DETECTION(Check all that apply)(A dacition ofthe mostitoling program shall be aubmiuel to the be.]agency) UNDERGROUND PIPING ABOVEGROUND PIPING SINGLE WALL PIPING 466, SINGLE WALL PIPING 467. PRESSURIZED PIPING(Check all that apply): PRESSURIZED PIPING(Check all that apply): ❑1. ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP [11. ELECTRONIC LINE LEAK DETECTOR 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 0 2, MONTHLY 0.2 GPH TEST [13. ANNUAL INTEGRITY TEST(0.1 GPH) 03. ANNUAL INTEGRITY TEST(0.1 GPH) [14. DAILY VISUAL CHECK CONVENTIONAL SUCTION SYSTEMS CONVENTIONAL SUCTION SYSTEMS(Check all that apply) ❑5. DAILY VISUAL MONITORING OF PUMPING SYSTEM+TRIENNIAL PIPING [15. DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM INTEGRITY TEST(0.1 GPH) SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): [16. TRIENNIAL INTEGRITY TEST(0.1 GPH) [17. SELF MONITORING SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): GRAVITY FLOW 07. SELF MONITORING [19. BIENNIAL INTEGRITY TEST(0.1 GPH) GRAVITY FLOW(Check all that apply): 0 8. DAILY VISUAL MONITORING O 9. BIENNIAL INTEGRITY TEST(0.1 GPH) SECONDARILY CONTAINED PIPING SECONDARILY CONTAINED PIPING PRESSURIZED PIPING(Check 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 one) ALARMS AND(Check one) 0 a. AUTO PUMP SHUT OFF WHEN A LEAK OCCURS ❑a. AUTO PUMP SIM OFF WHEN A LEAK OCCURS 0 It. AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM ❑b.AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM DISCONNECTION DISCONNECTION 0c. NO AUTO PIMP SHUT OFF Oc. NO AUTO PUMP SHUT OFF 0 11. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)WITH FLOW SHUT 0 11 AUTOMATIC LEAK DETECTOR OFF OR RESTRICTION 0 12. ANNUAL INTEGRITY TEST(0.1 GPH) 0 12. ANNUAL INTEGRITY TEST(0.1 GPH) SUCTION/GRAVITY SYSTEM SUCTION/GRAVITY SYSTEM 013. CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS 013.CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS EMERGENCY GENERATORS ONLY(Check all that apply) EMERGENCY GENERATORS ONLY(Check all that apply) 014. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF [114.CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF AUDIBLE AND VISUAL ALARMS AUDIBLE AND VISUAL ALARMS 015. AUTOMATIC LINE LEAK DETECTOR (3.0 GPH TEST) WITHOUT FLOW 0 15. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST) SHUT OFF OR RESTRICTION 016. ANNUAL INTEGRITY TEST(0.1 GPH) 0 16. ANNUAL INTEGRITY TEST(0.1 GPH) 0 IZ DAILY VISUAL CHECK 0 17. DAILY VISUAL CHECK VIII.DISPENSER CONTAINMENT DISPENSER CONTAINMENT 468. 0 1. FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE [14. DAILY VISUAL CHECK 469, DATE INSTALLED 0 2. CONTINUOUS DISPENSER PAN SENSOR+AUDIBLE AND VISUAL ALARMS 0 S. TRENCHILINER MONITORING Unknown DISPENSER 3. CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR 0 6. NONE DISPENSER+AUDIBLE AND VISUAL ALARMS IX.OWNER/OPERATOR SIGNATURE I certify that the i ormation ovided herein is true an accurate to the best of my knowledge. SIGNATURE OF O OF OR DATE: Ona NAME OF OR/OPERATOR(pr0t) MIC ael Walton TITLE OF OWNER/OPERATOR: Contractor eR. Permit Number(Agency use only) 473 1 Permit Approved By(Agency use only) 474. Permit Expiration Date(Agency use only) 475. UPCF hwfwre-b(I/99)-3/4 http://www.unidocs.org Rev.02/16/00