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�NIFIED PROGRAM CONSOLIDATED FOR TANK: TA0504864 • PR#: PRO231173 FAC#: FA0006423 UNDERGROUND STORAGE TANKS - TANK PAGE 2 VI.PIPING CONSTRUCTION(Chea all wt apply) Paas 7of7 UNDERGROUND PIPING ABOVEGROUND PIPING SYSTEM TYPE M L PRESSURE ❑ 2.SUCTION ❑ 3.GRAVITY 458 ❑ 1.PRESSURE ❑ 2.SUCTION ❑ 3.GRAVITY 459 CONS RUCnON ❑1.SINGLE WALL ❑3.LINED TRENCH ❑ 99.OTHER 460 ❑ 1,SINGLE WALL ❑ 95.UNKNOWN 462 ®2.DOUBLE WALL ❑95.IINKNOWN El 2.DOUBLE WALL El 99.OTHER MANUFACTURER 461 MANUFACTURER 463 ❑ L BARE STEEL ❑ 6.FRP COMPATIBLE,,/100%MEIHANOL ❑ 1.BARE STEEL ❑ 6.FRP COMPATIBLE W I W%METHANOL ❑2.STAINLESS STEEL ❑ 7.GALVANIZEDSTEEL ❑ 2.STAINLESS STEEL ❑ 7.GALVANIZED STEEL ❑PLASTIC COMPATIBLE W/CONTENTS ❑ 95.UNKNOWN ❑ PLASTIC COMPATIBLE W/CONTENTS ❑ 95.UNKNOWN M 4.FIBERGLASS ❑ S.FLEXIBLE(HDPE) ❑ W OTHER ❑ 4.FIBERGLASS [18.FLEXIBLE(HDPE) ❑ 99.OTHER ❑5.STEEL W/COATING ❑9.CATHODIC PROTECTION 464 ❑ 5.STEEL W/COATING ❑ 9.CATHODIC PROTECTION 465 VII.PIPING LEAK DETECTION(Check a 11 uut apply)(AGx�ptien ofua monitmin8 pmgram shall be svbmim6to 6a local e,,n ) UNDERGROUND PIPING ABOVEGROUND PIPING SINGLE WALL PIPING466 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 ❑ I.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) F1 S.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(03 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(Clack ore) ALARMS AND(Ch d,ma) M 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 SHAT OFF ❑ c. NO AUTO PUMP SHUT OFF ❑ 11.AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)WITH FLOW SHUT OFF OR ❑ I 1 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(Chea all that appy) EMERGENCY GENERATORS ONLY(Check au 0w 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 VOL DISPENSER CONTAINMENT DISPENSER CONTAINMENT ® I.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 469 IX.OWNER/OPERATOR SIGNATURE 1 arti5'thm the mfomuuon provided Mann u tme aM accurate torte beat a.krca lo*' SIGNATURE qf.QWNERJOPERAJOR DATE 470 1 ;IY 7 I I O NAME OFO OPERATO (print) TITLED OWN OPERATOR 471 472 R-t Number(For bW use only) 473 Permit Appmv (For loM use My) 474 Pnmh ErPimtion Date(For 10 use any) 475 PT0002013 EE0000817 12/31/2005 12:00:OOAM UPCF(12/99 revised)