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41FIED PROGRAM CONSOLIDATED FORN TANK: TA0253501 W PR#: PR0232535 UNDERGROUND STORAGE TANKS - TANK PAGE 2 FAC#: FA0003692 VI.PIPING CONSTRUCTION(c km lbat apply) Page 3 On UNDERGROUND PIPING ABOVEGROUND PIPIDIG SYSTEM TYPE ❑ L.PRESSURE ❑ 2.SUCTION ❑ 3.GRAVITY 456 ❑ I.PRESSURE ❑ 2.SUCTION ❑ 3.GRAVITY 459 MNSMUI OON ❑1.SINGLE WALL ❑3.LME.TRENCH ❑ 99.OTHER 460 ❑ 1.SINGLE WALL ❑ 95.UNKNOWN 451 ❑2.DOUBLEWALL 095.UNKNOWN El 2.DOUBLE WALL ❑ WOTHER MANUFACTURER ml MANUFACTURER 463 ❑ 1.BARE STEEL ❑ 6.FRP COMPATIBLE wi 100X METHANOL ❑ 1.BARE STEEL ❑6.FRP COMPATIBLE w/l Oox METHANOL ❑ 2.STAINLESS STEEL ❑ 7.GALVANIZED STEEL ❑ 2.STAINLESS STEEL ❑ 7.GALVANIZED STEEL ❑ PLASTIC COMPATIBLE W/CONTENTS ❑ 95.UNKNOWN ❑ PLASTIC COMPATIBLE W/CONTENTS ❑95.UNKNOWN ❑ 4.FIBERGLASS ❑ 8.FLEXIBLE(HDPE) ❑ W OTHER ❑ 4.FIBERGLASS ❑S.FLEXIBLE(HDPE) ❑ 99.OTHER ❑ 5.STEEL W/COATING ❑9.CATHODIC PROTECTION aw ❑ 5.STEEL W/COATING ❑9.CATHODIC PROTECTION 465 VIL PIPING LEAK DETECTION(Checkall that aypy)(A da nIauon ofine m9niwnngpmg shall besubmlaed to ms 1.1 agmsy) UNDERGROUND PIPING ABOVEGROUND PIPING SINGLE WALL PIPING 466 SINGLE WALL PIPING 467 PRESSURIZED PIPING(Check all that apply): PRESSURIZED PIPING(Check all that apply): ❑ I.ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP SHUT OFF ❑ I.ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP SHUT OFF FOR LEAR,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 El❑3.ANNUAL INTEGRITY TEST(0.1 GPH) 2.MONTHLY 0.2 GPH TEST El3.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) [16.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(0.0 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(Click ma) ALARMSAND(C ama) ❑ 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 ❑ 11.AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)WITH FLOW SHUT OFF OR RESTRICTION El AUTOMATIC LEAK DETECTOR ❑ 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(Cbwk all mat appy) EMERGENCY GENERATORS ONLY(Check all 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 GPH TEST)WITHOUT FLOW ❑ IS.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 VIII.DISPENSER CONTAINMENT DISPENSERCONTAINMENT ❑ 1.FLOAT MECHANISM THAT SHUTS OFF SHEARVALVE ❑4.DAILY VISUAL CHECK DATE INSTALLED 46g2.CONTINUOUS DISPENSER PAN SENSOR AUDIBLE AND VISUAL ALARMS ❑ [15.TRENCH LINER/MONITORING ❑ 3.CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR ❑6.NONE DISPENSER+AUDIBLE AND VISUAL ALARMS 469 IX.OWNER/OPERATOR SIGNATURE 1 certify mat the mfvaati9n pt &i Mein is aM acewale w the bnt ofmy E49wledge. SIGNATURE OF OWNER/OPERATOR DATE 470 NAME OF OW NER1OPERATOR(p1m1) TITLE OF OWNER/OPERATOR 471 471 Pm nNw a(Fofbal me only) 473 P=ui Al,,- UFm I.I.oaly) 474 Pemnt Expi.ion Da4(Fm tont meanly) 475 PT0004139 EE0003804 12/31/1999 UPCF(12/99 revised)