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•ONIFIED PROGRAM CONSOLIDATED FOi� ` TANK: 'TA0504864 4 fl ll PH It: PRO231173 F ,n FAC#: FA0006423 UNDERGROUND STORAGE TAA KS - TANK PAGE 2 VI.PIPING CONSTRUCTION(cb all 0utapply) PW7of7 UNDERGROUND PIPING ABOVEGROUND PIPING SYSTEM TYPE ® 1.PRESSURE [:12.SUCTION ❑ 3.GRAVITY 458 ❑ 1.PRESSURE ❑ 2.SUCTION [13.GRAVITY 459 CONSTRUCDON ❑1.SINGLE WALL ❑3.LINED TRENCH [:199.OTHER 460 ❑ 1.SINGLE WALL ❑95.UNKNOWN m2 ®2.DOU E WALL ❑ .UN OWN [12.DOUBLE WALL ❑ 99.OTHER MANUFACTURER 95a61 MANUFACTURER 463 ❑ 1.BARE STEEL ❑ 6.FRP COMPATIBLE w/100%MRfHANOL ❑ 1.BARE STEEL ❑6.FRP COMPAT03LE wl 100v.METHANOL ❑ 2.STAINLESS STEEL ❑ 7.GALVANIZED STEEL ❑ 2.STAINLESS STEEL ❑7.GALVANIZED STEEL ❑ PLASTIC COMPATIBLEW/CONTENTS ❑ 95.UNKNOWN ❑ PLASTICCOMPATIBLEW/CONTENTS ❑95.UNKNOWN M 4.FIBERGLASS ❑8.FLEXIBLE(HDPE) ❑ 99.OTHER ❑4.FIBERGLASS ❑ 8.FLEXIBLE(HDPE) ❑99.OTHER ❑ 5.STEEL W/COATING ❑9.CATHODIC PROTECTION 464 ❑ 5.STEEL W/COATING ❑9.CATHODIC PROTECTION 465 VIL PIPING LEAK DETECTION{c mfl flat apply)(Adadptien :hill be eubmhtdta aw lad ere y.) 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 ❑ 1.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 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) F-15.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(O.0 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.0 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 ALARMSS RAND(Clwekane) ALARMS AND(Chwk ane) 1 .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 111.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(Cask all td wPN) EMERGENCY GENERATORS ONLY(C'hmk ill tat 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 15.AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)WITHOUT FLOW ❑ 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 VIII.DISPENSER CONTAINMENT DISPENSER CONTAINMENT ® 1.FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE ❑4.DAILY VISUAL CHECK DATE INSTALLED 469 ❑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 a6v IX.OWNER/OPERATOR SIGNATURE I unify ow theinramutim pmNEealwcin u sue ab arcwate to Mebmt ormy knowlNge. SIGNATURE OF OWNER/OPERATOR. DATE 470 NAME OF OWNERIOPERATOR(print) TITLE OF OWNER/OPERATOR Oil 472 P.it Nwnber(Forladi .nIy) 473 Pwmit Appmai(Fwlodwconly) 474 PermitPpkatim Datc(Fwlodwea y) 475 PT0002013 EE0001273 12/31/2008 12:00:OOAM UPCF(12/99 revised)