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UNIFIED PROGRAM CONSOLIDATED FORIR' TANK: TA0508398 PR#: PR0505/51 FAC#: FA0007815 UNDERGROUND STORAGE TANKS -TANK PAGE 2 VL PIPING CONSTRUCTION(cnaa all aat aRly) Page]on UNDERGROUND PIPING ABOVEGROUND PIPING SYSTEM TYPE X 1.PRESSURE ❑ 2.SUCTION ❑ 3.GRAVITY 458 ❑ 1.PRESSURE ❑2.SUCTION ❑ 3.GRAVITY 459 CONSTRUCTION ❑1.SINGLE WALL ❑3.LINED TRENCH ❑ 99.OTHER 450 ❑ L SINGLE WALL ❑ 95.UNKNOWN 4ss 2.DOUBLE WALL 5.UNKNOW E] 2.DOUBLE WALL ❑ 99.OTHER MANUFACTURE ❑9ml MANUFACTURER 463 ❑ I.BARE STEEL ❑ 6.FRP COMPATIBLE w/10CMMETHAN01, ❑ I.BARE STEEL ❑ 6.FRP COMPATIBLE V IW%METHANOL ❑ 2.STAINLESS STEEL ❑ ].GALVANIZED STEEL ❑ 2.STAINLESS STEEL ❑ ].GALVANIZED STEEL ❑PLASTIC COMPATIBLE W/CONTENTS ❑ 95.UNKNOWN ❑ PLASTIC COMPATIBLE W/CONTENTS ❑ 95.UNKNOWN 4.FIBERGLASS ❑ 8.FLEXIBLE(HDPE) ❑ 99.OTHER ❑ 4.FIBERGLASS [I8.FLEXIBLE(HDPE) E] 99.OTHER 5.STEEL W/COATING ❑ 9.CATHODIC PROTECTION 454 ❑ 5.STEEL W/COATING ❑ 9.CATHODIC PROTECTION 155 VII.PIPING LEAK DETECTION(Lb 0thaz apply)(Ael-ipam orate umimrs,,ptpganlehWl 6e ammrinw maslpd agemy) UNDERGROUND PIPING ABOVEGROUND PIPING SINGLE WALL PIPING 455 SINGLE WALL PIPING 457 PRESSURIZED PIPING(Cheek 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 WIT F AUTO PUMP SHUT OFF FOR LEAK.SYSTEM FAILURE.AND SYSTEM DISCONNECTION+AUDIBLE AND FOR LEAK,SYSTEM FAILURE,AND SYSTEM DISCONNECTION+AUDIBLE AND VISUAL ALARMS. VISUALALARMS. ❑2.MONTHLY 02 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(Check all that apply) CONVENTIONAL SUCTION SYSTEMS E] 5.DAILY VISUAL MONITORING OF PUMPING SYSTEM+TRIENNIEAL PIPING ❑ 5.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): ❑ ].SELF MONTIORNG ❑ ].SELF MONITORING GRAVITY FLOW GRAVITY FLOW(Check all that apply): ❑9.BIENNIA.INTEGRITY TEST(0.1)GPH ❑ 8.DAILY VISUAL MONITORING ❑ 9.HIENMAL 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 ALARMSAND(L .) ALARMSAND(O arc) A❑t�a.AUTO PUMP SHUT OFF WHEN A LEAK OCCURS ❑ a.AUTO PUMP SHUT OFF WHEN A LEAK OCCURS Xb.AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM ❑b.AUTO PUMP SHUT OFF FOR LEAKS.SYSTEM FAILURE AND SYSTEM DISCONNECTION DISCONNECTION {�yT ❑c.NO AUTO PUMP SHUT OFF ❑ c.NO AUTO PUMP SHUT OFF �11.AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)WITH FLOW SHUT OFF OR ❑ 11.AUTOMATIC LEAK DETECTOR RESTRICTION ❑ 12.ANNUAL INTEGRITY TEST(0.1 GPH) ❑ 12.ANNUAL NTEGRITY 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(Ox 1 a tlw apply) EMERGENCY GENERATORS ONLY(CTak ill that apply) ❑ 14.CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF e ❑ 14.CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUTOFF- AUDIBLE HUTOFFeAUDIBLE 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 NTEGRITY TEST(0.1 GPH) ❑ 16.ANNUAL INTEGRITY TEST(0.1 GPH) ❑ 11.DAILY VISUAL CHECK ❑ 17.DAILY VISUAL CHECK VIII.DISPENSER CONTAINMENT DISPENSER CONTAINMENT ❑ 1.FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE ❑4.DAILY VISUAL CHECK DATE INSSTTAJJALLED 458 ❑2.CONTINUOUS DISPENSER PAN SENSOR+AUDIBLE AND VISUAL ALARMS ❑ 5.TRENCH LINER/MONITORING 1 �3.CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR ❑ 6.NONE DISPENSER+AUDIBLE AND VISUAL ALARMS 459 D(.OWNERIOPERATOR SIGNATURE Imayaatt iaran.uat ptwi6W lindnuweaM amvatcmtheant Oran tvwle�c SIGNATURE OF OWNER/OPERATOR DATE 00 NAME OF OWNER/OPERATOR(print) TITLE OF OWNEWOPERATOR n1 4n P-Nmrbw(Fslmlmemy) 473 Pettrvt Ahrytwed(Fmlaul uscwM Nm 4 Penm m t EViatirate ll me any) 475 PT0005454 EE0003804 12/31/1998 UPCF(12/99 revised)