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UNIFIED PROGRAM CONSOLIDATED FORV TANK: TA0508396 PR M: PRO505151 FAC N: FA0007815 UNDERGROUND STORAGE TANKS -TANK PAGE 2 VI.PIPING CONSTRUCTION(Chet,ei mat appy) Page 3 or7 UNDERGROUND PIPING ABOVEGROUND PIPING SYSTEM TYPE 1.PRESSURE ❑2.SUCTION ❑ 3.GRAVITY 458 ❑ 1.PRESSURE ❑2.SUCTION ❑ 3.GRAVITY 459 CONSTRUCTION ❑1.SINGLE WALL 03.LINED TRENCH ❑ 99.OTHER 460 ❑ L SINGLE WALL ❑ 95.UNKNOWN 462 �-.DOUBLE WALL ❑95. KNOWN ❑ 2.DOUBLE WALL El ".OTHER MANUFACTURER 461 MANUFACTURER 463 ❑ 1.BARE STEEL ❑ 6.1"COMPATIBLE W t00%METHANOL ❑ 1.BARE STEEL ❑ 6.FRP COMPATIBLE W IC934MEIB M ❑ 2.STAINLESS STEEL ❑ 7.GALVANIZED STEEL ❑ 2.STAINLESS STEEL ❑ 7.GALVANIZED STEEL ❑ PLASTICCOMPATIBLEW/CONTENTS ❑ 95.UNKNOWN ❑ PLASTIC COMPATIBLE W/CONTENTS ❑ 95.UNKNOWN �4.FIBERGLASS ❑ S.FLEXIBLE(HDPE) ❑ 99.OTHER ❑ 4.FIBERGLASS El 8.FLEXIBLE(HDPE) El99.OTHER 5.STEEL W/COATING ❑ 9.CATHODIC PROTECTION 469 ❑ S.STEEL W/COATING ❑ 9.CATHODIC PROTECTION 465 VIL PIPING LEAK DETECTION(a m tlue Wy)(A demipdm ofde a itcrlag pmeam.han hes Tint tome ml age y) 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 SHUT OFF ❑ 1.ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP SHUT OFF FOR LEAK,SYSTEM FAILURE.AND SYSTEM DISCONNECTION'AUDIBLE AND FOR LEAK,SYSTEM FAILURE,AND SYSTEM DISCONNECTION,AUDIBLE AND VISUAL ALARMS. VISUAL ALARMS. ❑ 2.MONTHLY 0.2 GPH TEST ❑ 2.MONTHLY 0.2 GPH TEST ❑ 3.ANNUAL INTEGRITY TEST(0.1 GPH) ❑ 3.ANNUAL INTEGRITY TEST(0.1 GPH) ❑ 4.DAILY VISUAL CHECK CONVENTIONAL SUCTION SYSTEMS CONVENTIONAL SUCTION SYSTEMS(Check all that apply) ❑ 5.DAILY VISUAL MONITORING OF PUMPING SYSTEM+TRIENMEAL PIPING ❑ S.DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM INTEGRITY TEST(0.1 GPH) ❑ 6.TRIENNIAL INTEGRITY TEST(0.1 GPH) SAFE SUCTION SYSTEMS(NO VALUES IN BELOW GROUNDPIPING): SAFE SUCTION SYSTEMS(NO VALUES IN BELOW GROUNDPIPING): ❑ 7.SELF MONITORING ❑ 7.SELF MONITORING GRAVITY FLOW ❑9.BIENNIAL INTEGRITY TEST(0.1)GPH GRAVITY FLOW(Check ell that apply): ❑ 8.DAILY VISUAL MONITORING [19.BIENNLLL 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 IO.CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL ALARMSAND(L me) ALARMSAND(Chmk.) ❑a.AUTO PUMP SHUT OFF WHEN A LEAK OCCURS ❑ a.AUTO PUMP SHUT OFF WHEN A LEAK OCCURS � .AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM ❑ b.AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM ISCONNECTION DISCONNECTION �.aa ❑ c.NO AUTO PUMP SHUT OFF ❑c.NO AUTO PUMP SHUT OFF mL l I.AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)WI.I.FI FLOW SHUT OFF OR ❑ 11 AUTOMATIC LEAK DETECTOR ( -RESTRICTION ❑ 12.ANNUAL INTEGRITY TEST(0.1 GPH) ❑ 12.ANNUAL INTEGRITY TEST(0.1 GPH) SUCTION/GRAVITY SYSTEM SUCTION/GRAVITY SYSTEM ❑ 13.CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS ❑ 13.CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS EMERGENCY GENERATORS ONLY(CMk all dun appy) EMERGENCY GENERATORS ONLY(Cheek JI dut>ppy) ❑ 14.CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF• ❑ 14.CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF a AUDIBLE AND VISUAL ALARMS AUDIBLE AND VISUAL ALARMS ❑ 15.AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)WITHOUT FLOW ❑ 15.AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)WITHOUT FLOW SHUT OFF OR RESTRICTION SHUT OFF OR RESTRICTION ❑ 16.ANNUAL INTEGRITY TEST(0.1 GPH) ❑ 16.ANNUAL INTEGRITY TEST(0.1 GPH) ❑ 17.DAILY VISUAL CHECK ❑ 17.DAILY VISUAL CHECK V W.DISPENSER CONTAINMENT DISPENSER CONTAINMENT ❑ 1.FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE ❑ C DAILY VISUAL CHECK DATE INSTALLED �8 �tF❑�2.CONTINUOUS DISPENSER PAN SENSOR+AUDIBLE AND VISUAL ALARMS E] 5.TRENCH LINER/MONITORING CONTINUa ! DISPENSER O+AUDIBLE AND VISUAL ALA MS US DISPENSER PAN SEPISOR H AUTO SHUT OFF FOR ❑ 6.NONE �9 IX.OWNER/OPERATOR SIGNATURE Imdty flat ds h:Tmmdun is cnic-I amvme to Reef any le-kdv.. SIGNATURE OF OWNER/OPERATOR DATE 470 NAME OF OWNER/OPERATOR(print) TITLE OF OWNER/OPERATOR 4]1 4]1 Par:it N:mber(Fvlvaluu Wy) 473 P-tApFm W(Fcakt :eemy) 474 Fmmt Expvatim Da¢(Fvlmlmemy) 475 PT0005454 EE0003804 12/31/1998 UPCF(12/99 revised)