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•fIFIED PROGRAM CONSOLIDATED FORA* TANK: TA0504863 PR#: PR0231173 FAC#: FA0006423 UNDERGROUND STORAGE TANKS -TANK PAGE 2 VI.PIPING CONSTRUCTION(aaa au thet apply) Pap 5 of7 UNDERGROUND PIPING 41N ABOVEGROUND PIPING ass SYSTEM TYPE - 1.PRESSURE ❑2.SUCTION LJ3.GRAVITYke ❑ 1.PRESSURE [-12.SUCTION El3.GRAVITY r 462 CONSTRUCTION r-1 �SINGLE WALL E33.LUDED TRENCH ❑99.OTHER 460 El 1.SINGLE WALL ❑ 95.UNKNOWN CTI DOUBLE WALL ❑95.UNKNOWN ❑ 2.DOUBLE WALL ❑ ".OTHER 463 MANUFACTURER MANUFACTURER ❑ 1.BARE STEEL ❑6.FRP COMPATIBLE od 10 .METHANOL ❑ 1.BARE STEEL ❑ 6.FRP COMPATIBLE ay 100%METHANOL ❑ 2.STAINLESS STEEL ❑ ].GALVANIZED STEEL ❑ 2.STAINLESS STEEL ❑ ].GALVANIZED STEEL F1 PLASTIC COMPATIBLE W/CONTENTS El 95.UNKNOWN ❑ PLASTIC COMPATIBLE W/CONTENTS El 95.UNKNOWN i 06MMWF,ASS ❑ S.FLEXIBLE(HDPE) ❑ ".OTHER E] 4.FIBERGLASS ❑ B.FLEXIBLE(HDPE) ❑ 99.OTHER F1 5.STEEL W/COATING ❑9.CATHODIC PROTECTION ❑ 5.STEEL W/COATING ❑ 9.CATHODIC PROTECTION 465 VD.1.0 LEAK DETECTION(Coeaka]l aat Wpl,)(Ademill.ofthemonitaoajocaoamsholhe sanucclto the Iota]ogenayMGING 467 UVG 466PRESSURIZED PIPIN (C a 1 at PRESSURIZED PIPING(Chec a 1 a appy❑ 1.SLECTRO'P (C LEA E OGPH TEST WITH AUTO PUMP SHUT OFF ❑ I.ELECTRONIC LME LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP SHUT OFF F R LEAK.S T M FAI RE, D SYS DISCONNECTION+AUDIBLE AND FOR LEAK.SYSTEM FAILURE,AND SYSTEM DISCONNECTION+pUDU3LE AND VISUAL ALA M VISUAL ALARMS. C] 2. ONTHLY 0.2 GPH T ❑ 2.MONTHLY 0.2 GPH TEST ❑ 3.ANNUAL INTEGRITY TEST(0.1 GPH) .ANNUAL MTEGRI TES (0.1 GP ❑ 4.DAILY VISUAL CHECK CONVENTIONAL SUCTION SYSTEMS(Check all that apply) CONVE}ry\T ZONAL SUCTION SY E}MS V I ❑ S.DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM INTEGRITY MONITO }r OF PII IQIGS TEM+iRIENNIEAl PIPING MTEOIUTY TEST(O.i GPH) I ❑ 6.TRIENNIAL INTEGRITY TEST(0.1 GPH) SAFE SUCTION SYSTEMS(NO VALUES IN LO GROUNDPIPING): SAFE SUCTION SYSTEMS(NO VALUES IN BELOW GROUNDPIPING): ❑ T SELF h10NITORING ❑ 7.SELFMONITORMG GRAVITY FLOW GRAVITY FLOW(Check all that apply): 4 9.BIENNIAL MTIRITY TEST(0.1)GPH �f (j ❑ 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 IM O.CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL A ALARMS AND(Co.) ❑ a.AUTO PUMP SHUT OFF WHEN A LEAK OCCURS PUMP SHUT OFF WHEN A LEAK OCCURS ❑It.AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM ❑6.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 ❑ 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(Cook all that appq) EMERGENCY GENERATORS ONLY(C an shot apply) ❑ 14.CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF• ❑ 14.CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF a AUDIBLE AND VISUAL ALARMS AUDIBLE AND VISUAL ALARMS 15.AUTOMATIC LME LEAK DETECTOR(3.0 GPH TEST)WITHOUT FLOW ❑ 15.AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)WITHOUT FLOW ❑ SSHUT OFF OR RESTRICTION HUT OFF OR RESTRICTION ❑ 16.ANNUAL INTEGRITY TEST(0.1 GPH) ❑ 16.ANNUAL INTEGRITY TEST(0.1 GPH) E] 17.DAILY VISUAL CHECK ❑ 1].DAILY VISUAL CHECK VIN.DISPENSER CONTAINMENT DISPENSERCONTAMMENT LOAT MECHANISM THAT SHUTS OFF SHEAR VALVE ❑ 4.DALLY VISUAL CHECK DATEINSTALLED 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 fig DISPENSER+AUDIBLE AND VISUAL ALARMS .OWNER/OPERATOR SIGNATURE I mcfy that the mtoantion 'dW toocia trot end coccate to the bet clot,qln Ic*. \' SIGNATURE OF OWN PERATOR DATE (� n NAME OF OWNER/OPERATOR(aowmfffprint) 411 TITLEOFOWNER/OPERATO 412 ( � 1 Pcmit Appmved(Fmloalwonly) 474 P<mtit Eapecate,Date(Fmbal us4 mdy) 415 Pamdt Nubtal ue anlY) 4,3 PT0002002013 EE0003804 12/31/2003 UPCF(12/99 revised)