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D PROGRAM CONSOLIDATED _ :M <br /> TANKS <br /> UjGROUND STORAGE TANKS - TANK PAGE 2 <br /> Pae of <br /> VI.PIPING CONSTRUCTION(chock a0 that a ply) <br /> ROUND PIPING ABOVEGROUNDPIPING <br /> SYSTEM TYPE ®1.PRES0 2.SUCTION 0 3.GRAVITY 458. 0 1.PRESSURE 0 2.SUCTION 0 3.GRAVITY 459CONSTRUCTION/ 0 1.SING0 3.LINED TRENCH 0 99.OTHER 460. 0 1.SINGLE WALL 0 95.UNKNOWN 462. <br /> MANUFACTURER ®2.DOU0 95.UNKNOWN 0 2.DOUBLE WALL 0 99.OTHER <br /> MANUFACTURER A.O. Smith 461' MANUFACTURER 463 <br /> -6-1.BARE STEEL 0 6.FRP COMPATIBLE W/100%METHANOL 0 L BARE STEEL ❑6.FRP COMPATIBLE W/100%METHANOL <br /> 0 2.STAINLESS STEEL 0 7.GALVANIZED STEEL 0 2.STAINLESS STEEL 0 7.GALVANIZED STEEL <br /> 0 3.PLASTIC COMPATIBLE WITH CONTENTS 0 95.UNKNOWN 0 3.PLASTIC COMPATIBLE W/CONTENTS 0 S.FLEXIBLE(HDPE) 0 99.OTHER <br /> 0 4.FIBERGLASS 0 8.FLEXIBLE(HDPE) 0 99.OTHER 0 4,FIBERGLASS 0 9.CATHODIC PROTECTION <br /> 0 5.STEEL W/COATING 0 9.CATHODIC PROTECTION 464. 0 5,STEEL W/COATING 0 95.UNKNOWN 465, <br /> VII.PIPDYG LEAK DETECTION(Check all that a I)(A dncAption of the monitoring tuoinuc 5he11 ba mbmitted w[he local ageacy) <br /> UNDERGROUND PIPING ABOVEGROUND PIPING <br /> SINGLE WALL PIPING a66. SINGLE WALL PIPING 467. <br /> PRESSURIZED PIPING(Check all that apply): PRESSURIZED PIPING(Check all that apply): <br /> 0 I. ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP 01. ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WJJH AUTO PUMP <br /> SHUT-OFF FOR LEAK,SYSTEM FAILURE,AND SYSTEM DISCONNECTION SHUT IBLE FOR <br /> VISUAL SYSTEM <br /> A FAILURE, <br /> A LURE,AND SYSTEM DISCONNECTION <br /> +AUDIBLE AND VISUAL ALARMS. <br /> [12, MONTHLY 0.2 GPH TEST [12. MONTHLY 0.2 GPH TEST <br /> 03. ANNUAL INTEGRITY TEST(0.1 GPH) 0 3. ANNUAL INTEGRITY TEST(0.1 GPH) <br /> 04. DAILY VISUAL CHECK <br /> CONVENTIONAL SUCTION SYSTEMS CONVENTIONAL SUCTION SYSTEMS(Check all that apply) <br /> 0 5. DAILY VISUAL MONITORING OF PUMPING SYSTEM+TRIENNIAL PIPING [15. DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM <br /> INTEGRITY TEST(0.1 GPH) <br /> SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): [16. TRIENNIAL INTEGRITY TEST(0.1 GPH) <br /> [17. SELF MONITORING SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): <br /> GRAVITY FLOW 0 7. SELF MONITORING <br /> 0 9. BIENNIAL INTEGRITY TEST(0.1 GPH) GRAVITY FLOW(Check all that apply): <br /> [19. DAILY VISUAL MONITORING <br /> 0 9. BIENNIAL INTEGRITY TEST(0.1 GPH) <br /> SECONDARILY CONTAINED PIPING SECONDARILY CONTAINED PIPING <br /> PRESSURIZED PIPING(Check all that apply): PRESSURIZED PIPING(Check all that apply): <br /> 10. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL 10. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL <br /> ALARMS AND(Check one) ALARMS AND(Check ane) <br /> 0 a. AUTO PUMP SHUT OFF WHEN A LEAK OCCURS 0 a. AUTO PUMP SHUT OFF WHEN A LEAK OCCURS <br /> 0 b. AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM 0 b. DAUTO PUMP SHUT ISCONNECTION OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM <br /> DISCONNECTION <br /> Oc. NO AUTO PUMP SHUT OFF Oc. NO AUTO PUMP SHUT OFF <br /> ®11. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)WITH FLOW SHUT 11 AUTOMATIC LEAK DETECTOR <br /> OFF OR RESTRICTION <br /> 12. ANNUAL INTEGRITY TEST(0.1 GPH) 0 12. ANNUAL INTEGRITY TEST(0.1 GPH) <br /> SUCTION/GRAVITY SYSTEM SUCTION/GRAVITY SYSTEM <br /> 0 13. CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS 0 13. CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS <br /> EMERGENCY GENERATORS ONLY(Check all that apply) EMERGENCY GENERATORS ONLY(Check all that apply) <br /> 014. CONTINUOUS SOW SENSOR WITHOUT AUTO PUMP SHUT OFF [114. CCONTIINUONSDSUMP ASLENSSOARIWITH OUT AUTO PUMP SHUT OFF <br /> AUDIBLE AND VISUAL ALARMS AUDIBLE <br /> 015. AUTOMATIC LINE LEAK DETECTOR (3.0 GPH TEST) WITHOUT FLOW 0 15. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST) <br /> SHUT OFF OR RESTRICTION <br /> [116. ANNUAL INTEGRITY TEST(0.1 GPH) ❑16. ANNUAL INTEGRITY TEST(0.1 GPH) <br /> 017, DAILY VISUAL CHECK ❑17. DAILY VISUAL CHECK <br /> VIII.DISPENSER CONTAINMENT <br /> DISPENSER CONTAINMENT 468. 0 1. FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE [14. DAILY VISUAL CHECK 469. <br /> DATE INSTALLED E12. CONTINUOUS DISPENSER PAN SENSOR+AUDIBLE AND VISUAL ALARMS 0 5. TRENCH/LINER MONITORING <br /> ®3. CONTINUOUS+AUDIBLEBLDISPENSERAND VIS ASLL ALARMS WITH AUTO SHUT OFF FOR 0 6. NONE <br /> Unknown DISPENSER <br /> tX.OWNER/OPERATOR SIGNATURE <br /> I certify that the information p ovided herein is true and urate to the best of my knowledge. <br /> SIGNATURE OF( OP OR .- DATE: 470 <br /> /m t * Q �o <br /> 472 <br /> NAME OF OWNS OPERATOR(print): Michael Walton TITLE OF OWNER/OPERATOR: Contractor _ <br /> Permit Number(Agency use only) 473. 1 Permit Approved By(Agency use only) 474. Permit Expiration Date(Agency use only) 475. <br /> UPCF hwfwrc-b(1/99)-3/4 http://www.unidoes.org Rev.02/16/00 <br />