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go 5 `nJNIF1ED PROGRAM CONSOLIDATED FORrw! TANK: TA05083% PRM: PRO505151 UNDERGROUND STORAGE TANKS - TANK PAGE 2 FAC N: FA0007815 VI.PIPING CONSTRUCTION(C1 kali Naz apphl Pap,3 o82 UNDERGROUND PIPING ABOVEGROUND PIPING SYSTEM TYPE ® I.PRESSURE ❑ 2.SUCTION ❑ 3.GRAVITY 458 ❑ L PRESSURE ❑ 2.SUCTION ❑ 3.GRAVITY 459 CONSTRUCTION ❑I.SINGLE WALL ❑3.LIKED TRENCH ❑ 99.OTHER 460 ❑ I.SINGLE WALL ❑ 95.UNKNOWN 462 ®2 DOUBLE WALL E:195.UNKNOWN ❑ 2.DOUBLE WALL ❑ 99.OTHER MANUFACTURER A O SMITH 461 MANUFACTURER 463 ❑ 1.BARE STEEL ❑ 6.FRP COMPATIBLE W 1 W%METHANOL ❑ L BARE STEEL ❑ 6.FRP COMPATIBLE W I OOY.MEDIANOL ❑ 2.STAINLESS STEEL ❑ T.GALVANIZED STEEL ❑ 2_STAINLESS STEEL ❑ ].GALVANIZED STEEL ❑ PLASTIC COMPATIBLEW/CONTENTS ❑ 95.UNKNOWN ❑ PLASTIC COMPATIBLE W/CONTENTS ❑ 95.UNKNOWN ®4.FIBERGLASS ❑8.FLEXIBLE(HDPE) ❑ 99.OTHER ❑4.FIBERGLASS ❑ 8.FLEXIBLE(HDPE) ❑ 99.OTHER ❑ 5.STEEL W/COATING ❑ 9.CATHODIC PROTECTION 460 ❑ 5.STEEL W/COATING ❑ 9.CATHODIC PROTECTION 465 VII.PIPING LEAK DETECTION(Oxtkall0w awh)(A am�imbn n[u9 mmcmiinR progom alWl ce 4amnitaa m Ore 19ra1 agmwy_) UNDERGROUND PIPING ABOVEGROUND PIPING SINGLE WALL PIPING 466 SINGLE WALL PIPING 467 PRESSURIZED PIPING(Check all that apply): PRESSURIZED PIPING(Cheek all that apply); ❑ 1.ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP SHUT OFF ❑ I.ELECTRONIC LIKE LEAK DETECTOR 3 0 GPM 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+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 ING VALUES IN BELOW GROUNDPIPING): ❑7.SELF MONITORING ❑ T.SELF MONITORING GRAVITY FLOW ❑9.BIENNIAL INTEGRITY TEST(0.1)GPH GRAVITY FLOW(Check all that apply): ❑ 8.DAILY VISUAL MONITORING ❑ 9.BIENNIAL INTEGRITY TEST(0.1)GPH SECONDARILY CONTAINED PIPING SECONDARILY CONTAINED PIPING PRESSURIZED PIPING(Check all that apply): PRESSURIZED PIPING(Check dl that apply): 10.CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL 10.CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL ALARMS AND(C an) ALARMS AND(Cb-) ® 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 ❑ IL AUTOMATIC LINE LEAK DETECTOR Ll 0 GPH TEST)WIT FLOW SHUT OFF OR ❑ 11 AUTOMATIC LEAK DETECTOR RESTRICTION ❑ 12.ANNUAL INTEGRITY TEST(0.1 GPM ❑ 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(Check all Dur apply) EMERGENCY GENERATORS ONLY(Check all tbar apph) ❑ 14.CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHAT OFF• ❑ 14.CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF AUDIBLE AND VISUAL ALARMS AUDIBLE AND VISUAL ALARMS ❑S15.AUTOMATIC LINE LEAK DETECTOR(3 0 GPH TEST)WITHOUT FLOW E] 15.AUTOMATIC LINE LEAK DETECTOR(3 0 GPH TEST)WITHOUT FLOW HUT OFF OR RESTRICTION SHUT OFF OR RESTRICTION ❑ 16.ANNUAL INTEGRITY TEST(0.1 GPH) ❑ 16.ANNUAL INTEGRITY TEST(0.1 GPM ❑ 17.DAILY VISUAL CHECK ❑ 17.DAILY VISUAL CHECK VILL DISPENSER CONTAINMENT DISPENSER CONTAINMENT ❑ 1.FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE ❑ 4.DAILY VISUAL CHECK DATE INSTALLED 068 ❑ 2,CONTINUOUS DISPENSER PAN SENSOR AUDIBLE AND VISUAL ALARMS ❑ 5.TRENCH LINER/MONITORING ® 3.CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR ❑ 6.NONE DISPENSER+AUDIBLE AND VISUAL ALARMS 4M IX.OWNER/OPERATOR SIGNATURE Ica h&A the infonrurim pmvidcd Mrein is rsuc and auar b the best olms'kmrrl ge. SIGNAT REOFOWNER/OPERATOR DATE 470 NAME OF WNER/OPERATOR(print) /_ TITLE OF OWNER/OPERATOR �S Cid Y��1 47t 472 Permit N.m (Forkazluseonh) 473 Nm6Appr (Forloolusemly) 474 P. ,t E%pirslm Wre(Forlo[aluxmb) 475 PT0005454 EE0003804 12/31/1998 12:00:OOAM UPCF(12/99 revised)