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a a *UNIFIED PROGRAM CONSOLIDATED FOR TANK: PR k: UNDERGROUND STORAGE TANKS - TANK PAGE 2 PAC N: VL PIPING CONSTRUCRON(than all that appy UNDERGRO PIPING Pagc3 ar3 ABOVEGROUND PIPING SYSTEM TYPE ❑ I.PRESSURE 2.SUCTION ❑3.GRAVITY 458 ❑ I,PRESSURE ❑ 2.SUCTION ❑ 3.GRAVITY 459 CONSTRUCTION ❑I.SINGLE WALL 03.LINED TRENCH ❑ 99.OTHER 460 ❑ 1,SINGLE WALL 1-195.UNKNOWN ❑2.DOUBLEWALL 095.UNKNOWN a62 MANU USER 461 ❑2.DOUBLE WALL ❑ 99.OTHER MANUFACTURER 463 I.BARE STEEL ❑ 6.FRP COMPATIBLE w/IM METHANOL ❑ L BARE STEEL ❑ 6.FRP COMPATIBLE w/IW%MED NOL ❑2.STAINLESS STEEL ❑ 1.GALVANIZED STEEL ❑2.STAINLESS STEEL ❑ T GALVANIZED STEEL ❑ PLASTIC COMPATIBLE W/CONTENTS ❑ 95.UNKNOWN ❑ PLASTIC COMPATIBLE W/CONTENTS ❑ 95.UNKNOWN ❑ 4.FIBERGLASS ❑ S.FLEXIBLE(HDPE) 1199,OTHER ❑ 4.FIBERGLASS ❑ 8.FLEXIBLE(HDPE) ❑99 OTHER ❑ 5.STEEL W/COATING ❑ 9.CATHODIC PROTECTION 464 ❑ 5.STEEL W/COATING ❑ 9.CATHODIC PROTECTION VR.PIPING LEAK DETECTION!Check all Nu apply U daunptien oflM1e monimrin6 pmemm diell be aubmined to the local Ageayy 465 UNDERGROUND PIPING SINGLE WALL IN AEOVEGROUND PIPING PRESSURIZED PIPING(Check all that apply): 466 SINGLE WALL PIPING PRESSURIZED PIPING(Check all that a 1 961 ❑ 1.ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST pp y 1` W TH AUTO PUMP SHUT OFF ❑ I.ELECTRONIC LME LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP SHUT OFF FOR LEAK,SYSTEM FAILURE,AND SYSTEM DISCONNECTION+AUDIBLE AND FOR LEAK,SVSTEM FAILURE,AND SYSTEM DISCONNECTION+gUDIBLE AND VISUAL ALARMS. ❑ 2.MONTHLY O.2 GPH TEST VISUAL ALARMS. ❑3.ANNUAL INTEGRITY TEST(0.1 GPH) ❑ 2.MONTHLY 0.2 GPH TEST ❑ 3.ANNUAL INTEGRITY TEST(0.1 GPH) ❑4.DAILY VISUAL CHECK CONVENTIONAL SUCTION SYSTEMS CONVENTIONAL SUCTION SYSTEMS(Check all that apply) El S.DAILY VISUAL MONITORING OF PUMPING SYSTEM+TRIENNIEAL PIPING ❑ S.DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM INTEGRITY TEST(O.I GPH) SAFVII&TION SYSTEMS(NO VALUES IN BELOW GROUNDPIPING): ❑ 6.TRIENNIAL INTEGRITY TEST(0.1 GPH) ET57 SELF MONITORING SAFE SUCTION SYSTEMS(NO VALUES IN BELOW GROUNDPIPING): GRAVITY FLOW ❑T.SELF MONITORING ❑9.BIENNIAL INTEGRITY TEST(0.1)GPH GRAVITY FLOW(Check all that apply): ❑ 8.DAILY VISUAL MONITORING SECONDARILY CONTAINED PIPING ❑ 9.BIENNIAL INTEGRITY TEST(0.1)GPH PRESSURIZED PIPING(Check all that apply):I SECONDARILY CONTAINED PIPING CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL PRESSURIZED PIPING(Check all that apply): ALARMS AND(Check and 10.CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL ALARMS AND(Check onc{ ❑ e.AUTO PUMP SHUT OFF W A LEAK OCCURS ❑ a.AUTO PUMP SHUT OFF WHEN A LEAK OCCURS ❑ b.AUTO PUMP SHUT OFF TO AKS,SYSTEM FAILURE AND SYSTEM ❑ b.AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM DISCONNECTIO DISCONNECTION ❑ c. NO AUTO PU PS OF ❑ c. NO AUTO PUMP SHUT OFF ❑ I I.AUTOMATIC LM EAK ET GPH TEST)WITH FLOW SHUT OFF OR RESTRICTION ❑ 11,AUTOMATIC LEAK DETECTOR ❑ 12.ANNUAL INWTITY SYS Y TES ( GP ❑ 12.ANNUAL INTEGRITY TEST(0.1 GPH) SUCTION/GRAVITY SYS EM SUCTION/GRAVITY SYSTEM ❑ II.COMM000S SUMPSENSO +AUDIBLE AND VISUAL ALARMS ❑ 13.CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS EMERGENCY CE ERATORS ONLY(Chen all Net apply EMERGENCY GENERATORS ONLY(Check all Nm appy ❑ 14.CONTINUOUS SUMP SENSOR WITHOt IT AUTO PUMP SHUT OFF• ❑ 14.CONTINUOUS SUMP SENSOR WITHOUT AUDIBLE AND VISUAL ALARMS AUDIBLEANDCONTINUOUS ALARMS IT OUT AUTO PUMP SHUT OFF ❑ 15.AUTOMATIC LME LEAK DETECTOR(3.0 GPH TEST)WITHOUT FLOW SHUT OFF OR RESTRICTION ❑ 15.AUTOMATIC LME LEAK DETECTOR(3.0 GPH TEST)WITHOUT FLOW SHUT OFF OR RESTRICTION ❑ 16.ANNUAL INTEGRITY TEST(0.1 GPH) ElEl 11.DAILY VISUAL CHECK 16.ANNUAL INTEGRITY TEST(0.1 GPH) ❑ 17.DAILY VISUAL CHECK VIII.DISPENSER CONTAINMENT DISPENSER CONTAINMENT ❑ LFLOATMECHANISM THAT SHUTS OFF SHEAR VALVE DATE INSTALLED ❑ 4.DAILY VISUAL CHECK ❑ 2.CONTINUOUS DISPENSER PAN SENSOR+AUDIBLE AND VISUAL ALARMS ❑ 5.TRENCH LINER/MONITORING ❑ A CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR ❑ 6.NONE DISPENSER+AUDIBLE AND VISUAL ALARMS 469 IX.OWNER OP SIGNATURE Jm ry Nat Nein! ionpmvided is nueW aumalem kmwlWga. SIGNATURE OF DATE 430 NAME OF OWN`R/OPERATO t) / ` If'O / TITLE OF R/ E A OR 1I Permit Numb:r(For lad uu only 413 412 Permit ApFmved(For local use ony 414 Permit INPlmkon DmgF.r lod umony 415 UPCF(12/99 revised)