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4 J?-,.,ED PROGRAM CONSOLIDATED,rr/ 11 o <br /> TANKS <br /> UNDERGROUND STORAGE TANKS - TANK PAGE 2 <br /> Pa a of <br /> VI.PIPING CONSTRUCTION(Cheek on mat appl) <br /> UNDERGROUND PIPING ABOVEGROUND PIPING <br /> SYSTEM TYPE N 1.PRESSURE [12.SUCTION 0 3.GRAVITY 458. 0 1.PRESSURE O 2.SUCTION 0 3.GRAVITY 459, <br /> CONSTRUCTION/ O I.SINGLE WALL 0 3.LINED TRENCH 0 99.OTHER a6o. ❑1.SINGLE WALL <br /> MANUFACTURER 095.UNKNOWN 462. <br /> ®2.DOUBLE WALL 0 95.UNKNOWN 0 2.DOUBLE WALL O 99.OTHER <br /> MANUFACTURER A.O. $nlltll 46t. MANUFACTURER 463 <br /> 1.BARE ARE STEEL 0 6.FRP COMPATIBLE W/100%METHANOL 0 L BARE STEEL 0 6.FRP COMPATIBLE W1100%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 1195.UNKNOWN 0 3.PLASTIC COMPATIBLE W/CONTENTS 0 8.FLEXIBLE(HDPE) 0 99.OTHER <br /> [14.FIBERGLASS 0 8.FLEXIBLE(HDPE) 0 99.OTHER [14.FIBERGLASS 119.CATHODIC PROTECTION <br /> ❑5.STEEL W/COATING 0 9.CATHODIC PROTECTION 464- 0 5.STEEL W/COATING 0 95.UNKNOWN 465. <br /> VII.PIPING LEAK DETECTION(Cheek a1 that ep ly) A descriPtion of the monitoring program 51,01 be sobmitual to the local ency.) <br /> UNDERGROUND PIPING ABOVEGROUND PIPING <br /> SINGLE WALL PIPING 466, SINGLE WALL PIPING 467 <br /> PRESSURIZED PIPING(Check all that apply): PRESSURIZED PIPING(Check all that apply): <br /> ❑ I. ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST MM AUTO PUMP [31. ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP <br /> SHUT-OFF FOR LEAK,SYSTEM FAILURE,AND SYSTEM DISCONNECTION SHUT OFF FOR LEAK,SYSTEM FAILURE,AND SYSTEM DISCONNECTION <br /> +AUDIBLE AND VISUAL ALARMS. +AUDIBLE AND VISUAL ALARMS. <br /> ❑2. MONTHLY 0.2 GPH TEST [32. MONTHLY 0.2 GPH TEST <br /> [13. ANNUAL INTEGRITY TEST(0.1 GPH) [13. ANNUAL INTEGRITY TEST(0.1 GPH) <br /> O 4. 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 05. DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM <br /> INTEGRITY TEST(0.1 GPH) <br /> SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): [36. TRIENNIAL INTEGRITY TEST(0.1 GPH) <br /> 0 7. SELF MONITORING SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): <br /> GRAVITY FLOW 07. SELF MONITORING <br /> [19. BIENNIAL INTEGRITY TEST(0.1 GPH) GRAVITY FLOW(Check all that apply): <br /> 08. DAILY VISUAL MONITORING <br /> 09. 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 WITEi AUDIBLE AND VISUAL <br /> ALARMS AND(Check one) ALARMS AND(Check one) <br /> O a. AUTO PUMP SHUT OFF WHEN A LEAK OCCURS 0 a. AUTO PUMP SHUT OFF WHEN A LEAK OCCURS <br /> ®b.AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM 0 b. AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM <br /> DISCONNECTION DISCONNECTION <br /> Oc. NO AUTO PUMP SHUT OFF Oc. NO AUTO PUMP SHUTOFF <br /> 0 11. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)WITH FLOW SHUT 0 I1 AUTOMATIC LEAK DETECTOR <br /> OFF OR RESTRICTION <br /> 0 12, ANNUAL INTEGRITY TEST(0.1 GPH) 0 12. ANNUAL INTEGRITY TEST(0.1 GPH) <br /> SUCTION/GRAVITV SYSTEM SUCTION/GRAVITY SYSTEM <br /> [113. CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS [113. 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 SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF [114. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF <br /> AUDIBLE AND VISUAL ALARMS AUDIBLE AND VISUAL ALARMS <br /> 0 15. 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) 0 16. ANNUAL INTEGRITY TEST(0.1 GPH) <br /> 017, DAILY VISUAL CHECK 0 17. DAILY VISUAL CHECK <br /> VID.DISPENSER CONTAINMENT <br /> DISPENSER CONTAINMENT 468. O 1, FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE [14. DAILY VISUAL CHECK 469. <br /> DATE INSTALLED [12. CONTINUOUS DISPENSER PAN SENSOR+AUDIBLE AND VISUAL ALARMS ❑5. TRENCH/LINER MONITORING <br /> Unknown 03. CONTINUOUS DISPENSER PAN SENSOR YM AUTO SHUT OFF FOR 0 6. NONE <br /> DISPENSER+AUDIBLE AND VISUAL ALARMS <br /> IX.OWNER/OPERATOR SIGNATURE <br /> I ccrtify that the information provide herein is true and accur to to the best of my knowledge. <br /> SIGNATURE OFOWNEA/ TO DATE: 470. <br /> I fo <br /> NAME OF OWNER/OP TOR(print): Michas Walton TITLEOFOWNER/OPERATOR: Contractor 472_ <br /> Permit Number(Agency use only) 470. Permit Approved By(Agency use only) 474. 1 Permit Expiration Date(Agency use only) 475. <br /> UPCF hwfwrc-b(1/99)-3/4 http://www.unidoes.org Rev.02/16/00 <br />