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a �FIED PROGRAM CONSOLIDATED FORM TANK: TA0505758 PR#: PRO231665 FAC#: FA0003714 UNDERGROUND STORAGE TANKS - TANK PAGE 2 VI.PIPING CONSTRUCTION(Ock all mat appy) Pap 3 an L NDLRGROUND PIPING ABOVEGROUND PIPING SYSTEM TYPE (9 I.PRESSURE ❑ 2.SUCTION ❑ 3.GRAVITY 459 ❑ 1.PRESSURE ❑ 2.SUCTION ❑ 3.GRAVITY 459 WNSTRUCBON El 1.SINGLE WALL ❑3.LINED TRENCH El 99.OTHER 4w El t.SINGLE WALL El 95.UNKNOWN 462 19 2.DOUBLE WALL E:195.UNKNOWN ❑ 2.DOUBLE WALL ❑99.OTHER MANUFACTURER 461 MANUFACTURER 463 ❑ I.BARE STEEL ❑ 6.FRP COMPATIBLE w/IM METHANOL ❑ 1.BARE STEEL ❑6.FRP COMPATIBLE w/IoUk 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) ❑ 99.0THER ❑ 4.FIBERGLASS ❑ 8.FLEXIBLE(HDPE) ❑ 99.OTHER ❑ 5.STEEL W/COATING ❑ 9.CATHODIC PROTECTION 464 ❑ 5.STEEL W/COATING ❑ 9.CATHODIC PROTECTION 465 VO.PIPING LEAK DETECTION(Chink all neat aptly)(A ammiption ormc wri arinepra,.m stall tor enbmilte4 to we local Money.) UNDERGROUND PIPING ABOVEGROUND PIPING SINGLE WALL PIPING 466 SINGLE WALL PIPING 467 PRESSURIZED PIPING(Check all that apply): PRESSURIZED PIPING(Check all that apply): 1.ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP SHUT OFF El1.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 VISUALALARMS. 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(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): ❑ S.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(Check one) ALARMS AND(C k ra) ❑ a.AUTO PUMP SHUT OFF WHEN A LEAK OCCURS ❑a.AUTO PUMP SHUT OFF WHEN A LEAK OCCURS DT b.AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM ❑ b.AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM w 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 ❑ 11.AUTOMATIC LEAK DETECTOR RESTRICTION ❑ 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(Check all mat apply) EMERGENCY GENERATORS ONLY(Cheek ail twt apply) ❑ 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 ❑ IS.AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)WITHOUT FLOW El 15.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 VOL DISPENSER CONTAINMENT DISPENSER CONTAINMENT ❑ 1.FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE ❑ 4.DAILY VISUAL CHECK DATE INSTALLED 468 ❑ 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 4w IX.OWNER/OPERATOR SIGNATURE I cenilylhat the mf lion wrvidM herein nue awl accmte t4 We bat ofmy lmowle* SIGNATURE OF OWNER/OPERATOR DATE 470 NAME OF OWNER/OPERATOR(print) TITLE OF OWNER/OPERATOR 4]I 472 Pemtit Nimbec/Pmlocal me aNY) 473 Permit AMrmW(For local we only) 474 Permit Expiration Date(For kra]we orJy) 475 PT0004304 EE0003804 12/31/1993 UPCF(12/99 revised)