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IFIED PROGRAM CONSOLIDATED FORK TANK: TA0504864 PR#: PRO231173 FAC#: FA0006423 UNDERGROUND STORAGE TANKS -TANK PAGE 2 VI.PIPING CONSTRUCTION(Cbak all mat wly) IPING Pagc7 ort UNDERGROUND PIPING ABOVEGROUND P3.GR SYSTEM TYPE URE ❑ 2.SUCTION ❑ 3.GRAVITY ❑ LPRESSURE ❑ 2.SUCTION ❑ 3.GRAVITY 659 CONSTRUCDON 63 []I SINGLE WALL [13.LINED TRENCH ❑ 99.OTHER 460 ❑ 1.SINGLE WALL ❑ 95.UNKNOWN WALL 095.UNKNOWN El2.DOUBLE WALL ❑ 99.OTHER 463 15 MANUFACTURER MANUFACTURER ❑ I.BARE STEEL ❑6.FRP COMPATIBLE w/109SMETRANOL ❑ 1.BARE STEEL ❑ 6.FRP COMPATIBLE wl IO METHANOL ❑ 2.STAINLESS STEEL ❑ 7.GALVANIZED STEEL ❑ 2.STAINLESS STEEL [:17.GALVANIZED STEEL ❑ PLASTIC COMPATIBLE W/CONTENTS ❑ 95.UNKNOWN ❑ PLASTIC COMPATIBLE W1 CONTENTS ❑ 95.UNKNOWN 4.FJWSW.ASS ❑ 8.FLEXIBLE(HDPE) ❑ 99.OTHER ❑ 4.FIBERGLASS ❑ e.FLEXIBLE(HDPE) ❑99.OTHER ❑ 5.STEEL W/COATING ❑9.CATHODIC PROTECTION 464 ❑ 5.STEEL W/COATING ❑ 9.CATHODIC PROTECTION q65 T ING LEAK DETECTION(a .Jj matW]y)(A 4aa1p0 orme amhainepm Six Subtmnc4twd' ER OUND G V PIP W I G 467 466 /bIncteaux PRESSURIZED PIPING(Chec aBtha apply): PRESSURIZED PIPING(Check all that apply): ❑ 1.ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP SHUT OFF ❑ 1.ELECTRONIC LME LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP SHUT OFF FOR LEAK,SYSTEM FAILURE,AND SYSTEM DISCONNECTION+AUDIBLE AND R ALARMS. FAILURE,AND SYSTEM DISCONNECTION+AUDIBLE AND V VISUALALARMS. ❑ 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(Check all that apply) CONVENTIONAL SUCTION SYSTEMS ❑ 5.DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM ❑ 5.DAILY VISUAL MONITORING OF PUMPING SYSTEM+TRIENNIEAL PIPING 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 GRAVITY FLOW(Check all that apply): ❑ 9.BIENNIAL INTEGRITY TEST(0.1)GPH ❑ 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(Cheek all that apply): 10.CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL 10.CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL ALARMS AND(Choi mc) ALARMS AND(LTaxk aa) ❑ a.AUTO PUMP SHUT OFF WHEN A LEAK OCCURS K 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 ❑ c.NO AUTO PUMP SHUT OFF .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 GENERATORS ONLY VISUAL ALARMS EMERGENCY GENERATORS ONLY(Oark ell mat apply) EMERGENCYSENSOR ERATOU OUTPUT PSHU apply) ❑ 14.CONTINUOUS SUMP SENSOR WITH AUTO PUMP SHUT OFF• ❑ 14.CONTINUOUS SUMP SENSOR W TH AUTO PUMP SHUT OFP AUDIBLE AND VISUAL ALARMS AUDIBLE AND VISUAL ALARMS 15.AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)WITHOUT FLOW SHUT OFF OR RESTRICTION ❑ AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)WITHOUT FLOW ❑ SHUT OFF OR RESTRICTION SH ❑ 16.ANNUAL INTEGRITY TEST(0.1 GPH) ❑ 16.ANNUAL INTEGRITY TEST(0.1 GPH) ❑ 17.DAILY VISUAL CHECK ❑ IZDAILYVISUALCHECK Vm.DISPENSER CONTAINMENT DISPENSER CONTAINMENT ECHANISM THAT SHUTS OFF SHEAR VALVE ❑ 4.DAILY VISUAL CHECK DATE INSTALLED 168 ❑ 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 169 DISPENSER+AUDIBLE AND VISUAL ALARMS WNER/OPERATOR SIGNATURE l anifymat mcinfwmationprovidNh laumxae4emvemb mebet ofnrylvwwledgc 470 SIGNATURE OF OWNEWOPERA o DATE '3 NAME OF OWNER/OPERATOR at y 41 / 471 TITLE OF OWNER/OPERA� 472 Pm tAppmvW(Fa Io ucmly) 474 Pcmut Expbatiw Datc(F"rb co*) 475 Pr4m[NwLa(Fa1o®Imeonly) 4,n EE0003804 12/31/2003 PT0002013 UPCF(12/99 revised)