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~UNIFIED PROGRAM CONSOLIDATED FORV TANK: TA0508397 PR#: PRVA5151 FAC#: FA0007815 UNDERGROUND STORAGE TANKS - TANK PAGE 2 VL PIPING CONSTRUCTION(�al ow.pv1y) Pale 501`7 UNDERGROUND PIPING ABOVEGROUND PIPING SYSTEM TYPE W.PRESSURE ❑ 2.SUCTION E] 3.GRAVITY 459 ❑ 1.PRESSURE ❑ 2.SUCTION El3.GRAVITY 459 CONSTRUCTION El 1.SINGLE WALL 03.LINED TRENCH ❑ ".OTHER 460 [:1 1.SINGLE WALL ❑ 95.UNKNOWN 462 2. UBLEWALL 95.UNKNOWN 02.DOUBLE WALL ❑ ".OTHER MANUFACTURER I1� KI MANUFACTURER 463 ❑ 1.BARE STEEL ❑6.FRP COMPATIBLE w/100%METHANOL ❑ 1.BARE STEEL ❑ 6.PRP COMPATIBLE V lava METHANOL ❑2.STAINLESS STEEL ❑ 7.GALVANIZED STEEL ❑ 2.STAINLESS STEEL ❑ 7.GALVANIZED STEEL ❑ PLASTICCOMPATIBLEW/CONTENTS ❑ 95.UNKNOWN ❑ PLASTICCOMPATIBLEW/CONTENTS ❑ 95.UNKNOWN 4.FIBERGLASS ❑ IL FLEXIBLE(HDPE) ❑ 99.OTHER ❑4.FIBERGLASS ❑ S.FLEXIBLE(HDPE) ❑ 99.OTHER ❑ i STEEL W/COATING C]9.CATHODIC PROTECTION 464 El 5.STEEL W/COATING [:19.CATHODIC PROTECTION 466 VD.PIPING LEAK DETECTION(m al nNtapply)(A 6aaiptlm offs naiam9 pm®etnahall be eabnaed mina 1pol e9 y.) UNDERGROUND PIPING ABOVEGROUND PIPING SINGLE WALL PIPING 466 SINGLE WALL PIPING 467 PRESSURIZED PIPING(Check dl that apply): PRESSURIZED PIPING(Check all that apply): ❑ 1.ELECTRONIC LINE LEAK DETECTOR 3.0 GPM TEST WITH AUTO PUMP SHUT OFF ❑ 1.ELECTRONIC LINE LEAK DETECTOR 3.0 GPM TEST WITH AUTO PUMP SHUT OFF FOR LEAN(,SYSTEM FAILURE,AND SYSTEM DISCONNECTION'AUDIBLE AND FOR LEAK,SYSTEM FAILURE,AND SYSTEM DISCONNECTION+AUDIBLE AND VISUAL ALARMS. VISUAL ALARMS. ❑ 2.MONTHLY 02 GPM TEST ❑ 2.MONTHLY 0.2 GPM TEST ❑ 3.ANNUAL INTEGRITY TEST(0.1 GPM) ❑3.ANNUAL INTEGRITY TEST(0.1 GPM) ❑ 4.DAILY VISUAL CHECK CONVENTIONAL SUCTION SYSTEMS CONVENTIONAL SUCTION SYSTEMS(Check all that apply) ❑ 5.DALLY VISUAL MONITORING OF PUMPING SYSTEM+TRIENNIF.AL PIPING ❑ 5.DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM INTEGRITY TEST(0.1 GPM) ❑ 6.TRIENNIAL INTEGRITY TEST Mll GPM) SAFE SUCTION SYSTEMS(NO VALUES IN BELOW GROUNDPIPING): SAFE SUCTION SYSTEMS(NO VALUES IN BELOW GROUNDPIPING): ❑7.SELF MONITORING ❑ ].SELF MONITORING GRAVITY FLOW ❑9.BIENNI.LL.INTEGRITY TEST(0.1)GPM GRAVITY FLOW(Check all that apply): ❑ S.DAILY VISUAL MONITORING ❑ 9.BIENNIAL INTEGRITY TEST(0.1)GPM 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 AL kMSAND(CLedi.) ALARMSAND(Chetme) ❑ .aE]a.AUTO PUMP SHUT OFF WHEN A LEAK OCCURS [:] a.AUTO PUMP SHUT OFF WHEN A LEAK OCCURS ¢ b.AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM b.AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM /DISCONNECTION DISCONNECTION ❑c.NO AUTO PUMP SHUT OFF ❑c.NO AUTO PUMP SHUT OFF 14 11.AUTOMATIC LME LEAK DETECTOR(3.0 GPM TEST)WITH FLOW SHUT OFF OR ❑ 11 AUTOMATIC LEAK DETECTOR TRICTION ❑ 12.ANNUAL INTEGRITY TEST(0.1 GPM) ❑ 12.ANNUAL INTEGRITY TEST(0.1 GPM) 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(Q all slut appy) EMERGENCY GENERATORS ONLY(LTaak at that appy) ❑ 14.CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF• ❑ 14.CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF AUDIBLE AND VISUAL ALARMS AUDIBLE AND VISUAL ALARMS 15.AUTOMATIC LINE LEAK DETECTOR(3.0 GPM TEST)WITHOUT FLOW ❑ I5.AUTOMATIC LINE LEAK DETECTOR(3.0 GPM TEST)WITHOUT FLOW ❑ SHUT OFF OR RESTRICTION SHUT OFF OR RESTRICTION ❑ 16.ANNUAL INTEGRITY TEST(0.1 GPM) ❑ 16.ANNUAL INTEGRITY TEST(0.1 GPM) ❑ 17.DAILY VISUAL CHECK ❑ 17.DAILY VISUAL CHECK VDI.DISPENSER CONTAINMENT DISPENSER CONTAINMENT ❑ 1.FLOAT MECHANISM THAT SMUTS OFF SHEAR VALVE ❑ C DAILY VISUAL CHECK DATE INSTALLED 469 ❑ 2.CONTINUOUS DISPENSER PAN SENSOR+AUDIBLE AND VISUAL ALARMS ❑ 5.TRENCH LINER/MONITORING �C/) �3.CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR ❑ 6.NONE ` DISPENSER AUDIBLE AND VISUAL ALARMS 469 IX.OWNERIOPERATOR SIGNATURE l teary the u,c i0r ianpmndei hacm 6 nae aw.anew t0 tneteat oTny1 icdw.. SIGNATURE OF OWNEWOPERATOR DATE 470 NAME OF OWNER/OPERATOR(print) TITLE OF OWNER/OPERATOR 4]I 472 Peal Nwtba(Im brat uc only) 473 Pant App (Pce1=1weaJy) 474 Pant Epiniim Date(Fm local ase my) 475 PT0005454 EE0003804 12/31/1998 UPCF(12/99 revised)