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glob • `.dNIFIED PROGRAM CONSOLIDATED FORIlPoO' TANK: TA0508398 • PR p: PR0505151 UNDERGROUND STORAGE TANKS -TANK PAGE 2 FAC N; FA0007815 VI.PIPING CONSTRUCTION(Cnw-k ill Netali Pea,7o.3 UNDERGROUND PIPING ABOVEGROUND P[PMG SYSTEM TYPE ❑ I.PRESSURE ❑ 2.SUCTION ❑ 3.GRAVITY 458 ❑ 1.PRESSURE ❑ 2.SUCTION ❑ 3.GRAVITY 455 CONSTRucTION ❑1.SINGLE WALL ❑3.LINED TRENCH ❑ 99.OTHER 460 ❑ I.SINGLE WALL ❑ 95.UNKNOWN 462 ❑2.DOUBLE WALL ❑95.UNKNOWN ❑ 2.DOUBLE WALL ❑ ",OTHER MANUFACTURER ml MANUFACTURER 463 ❑ I.BARE STEEL ❑6.FRPCOMPATIBLEn91m9sMETHAN0L ❑ 1.BARE STEEL ❑ 6.FRP COMPATIBLE W IN%METHANOL ❑2.STAINLESS STEEL ❑ 7.GALVANIZED STEEL ❑ 2.STAINLESS STEEL ❑ 7.GALVANIZED STEEL ❑ PLASTIC COMPATIBLE W/CONTENTS [:1 95 UNKNOWN ❑ PLASTIC COMPATIBLE W/CONTENTS El 95 UNKNOWN ❑4.FIBERGLASS ❑ 8.FLEXIBLE(HDPE) ❑ ",OTHER ❑ 4.FIBERGLASS ❑ 8.FLEXIBLE(HDPE) ❑ 99.OTHER ❑ 5.STEEL W/COATING ❑ 9.CATHODIC PROTECTION 464 ❑ 5.STEEL W/COATING ❑ 9.CATHODIC PROTECTION 40 VII.PIPING LEAK DETECTION(crack d1 Na 11h)(A ilesvipuoioftnc rNer riell Pragraasnarl be nobmiuutwIle lom agua...) UNDERGROUND PIPING ABOVEGROUND PIPING SINGLE WALL PIPING 4% SINGLE WALL PIPING 461 PRESSURIZED PIPING(Check all that apply): PRESSURIZED PIPING(Cheek all that apply): ❑ 1.ELECTRONIC LME LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP SHUT OFF ❑ L 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 02 GPH TEST ❑ ;.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(NO VALUES IN BELOW GROUNDPIPING): ❑ 7.SELF MONITORING ❑ 7.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 all that apply): 10.CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL 10.CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL ALARMS AND(Creak arc) ALARMS AND(01-) ® a.AUTO PUMP SHUT OFF WHEN A LEAK OCCURS ❑ a.AUTO PUMP SHUT OFF WHEN A LEAK OCCURS ® Is 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 ❑ 11 AUTOMATIC LINE LEAK DETECTOR OT)GPH TEST)WITH FLOW SHUT OFF OR ❑ It AUTOMATIC LEAK DETECTOR RESTRICTION ❑ 12.ANNUAL INTEGRITY TEST(0.1 GPH) ❑ 12.ANNUAL INTEGRITY TEST(0.1 GPH) SUCTION/GRAVITY SYSTEM SUCTION/GRAVITY SYSTEM ❑ U.CONTINUOUS SUMP SENSOR AUDIBLE AND VISUAL ALARMS ❑ 13.CONTINUOUS SUMP SENSOR AUDIBLE AND VISUAL ALARMS EMERGENCY GENERATORS ONLY(Cbcck all Net apply) EMERGENCY GENERATORS ONLY(Clerk all Na apph) ❑ I4.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 0 0 GPH TEST)WITHOUT FLOW ❑ 15.AUTOMATIC LINE LEAK DETECTOR(3 0 GPH TEST)WITHOUT FLOW SHUT OFF OR RESTRICTION SHUT OFF OR RESTRICTION ❑ I6.ANNUAL INTEGRITY TEST III I GPH) ❑ 16.ANNUAL INTEGRITY TEST(0.1 GPH) ❑ 17.DAILY VISUAL CHECK ❑ 17.DAILY VISUAL CHECK VIII.DISPENSER CONTAINMENT DISPENSER CONTAINMENT ❑ 1.FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE ❑ 4.DAILYVISUALCHECK DATE INSTALLED 4682.CONTINUOUS DISPENSER PAN SENSOR AUDIBLE AND VISUAL ALARMS ❑ ❑ S.TRENCH LINER/MONITORING ® 3.CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR ❑ 6.NONE DISPENSER+AUDIBLE AND VISUAL ALARMS 469 M OWNER/OPERATOR SIGNATURE I mtifi Naz the Womwion Poled hemn is to ait aurae w tla bat ofm kmxtWge. SIGNATURE OF ER/OPERATOR DATE 470 NAME OF OWNER/O �T�OR(print) {I _ G TITLED OPERATOR -b/vi N- Nanbcr lFa bd acaJy) 473 Permit ApesoiW(For lacal au cal.) 474 P-1 E,iretiw Dare IFor local use.1h) 475 PT0005454 EE0003804 12/31/1998 12:00:OOAM UPCF(12/99 revised)