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�NIFIED PROGRAM CONSOLIDATED FOR TANK: PR0231173 TA0504862 PR#: FAC#: FA0006423 UNDERGROUND STORAGE TANKS -TANK PAGE 2 VI.PIPING CONSTRUCTION(Lbmk all0ae wpy) Pere 3 on UNDERGROUND PIPING ABOVEGROUND PIPING SYSTEM TYPE T, p,(tESSURE ❑ 2.SUCTION ❑ 3.GRAVITY 458 ❑ 1.PRESSURE ❑ 2.SUCTION ❑ 3.GRAVITY 459 CON9TRULTION ❑Imo.SINGLE WALL 03.LINED TRENCH ❑ 99.OTHER 460 ❑ 2.DOUBLE WALL ❑ ".OTHER WN mi 1.SINGLE WALL y�I�T2,oYBLE WALL ❑95.UNKNOWN ❑ 463 MANUFACTURER MANUFACTURER ❑ 1.BARE STEEL ❑ 6.FRP COMPATIBLE w/I WBMETRANOL ❑ 1.BARE STEEL ❑ 6.FRP COMPATIBLE w/Icam METHANOL E] 2.STAINLESS STEEL ❑ 7.GALVANIZED STEEL ❑2.STAINLESS STEEL F-17.GALVANIZED STEEL 95 UNKNOWN ❑ PLASTIC COMPATIBLE W/CONTENTS ❑ 95.UNKNOWN ❑ PLASTIC COMPATIBLE W/CONTENTS ❑ 4.FIBERGLASS ❑ 8.FLEXIBLE(HDPE) ❑99.OTHER gERGLASS ❑ 8.FLEXIBLE(HDPE) ❑ 99.OTHER ❑ ❑5.STEEL W/COATING r-1 9.CATHODIC PROTECTION ❑ 5.STEEL W/COATING E]9.CATHODIC PROTECTION 465 VII.PIPING LEAK DETECTION(Chale•n m.t wvy)(Av^o^or'M�"matm."%w°®""'1"Ilne eannoae6 wurlo®I.s�r.l V GR D PIPING ER PIG IN 467 IN L P G 466 PRESSURIZED PIPING(Chec ithatappl: PRESSURIZED PIPING(Cheer chat apply): ❑ 1.ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP SHUT OFF ❑ 1.ELECTRONIC LIE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP SHUT OFF FOR LEAK,SYSTEM FAILURE,AND SYSTEM DISCONNECTION+AUDIBLE AND V SR)L KA,SYYST M FAILURE,AND SYSTEM DISCONNECTION+AUDIBLE AND 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(Check all that apply) CONVENTIONAL SUCTION SYSTEMS ❑ 5.DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM F1 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 MST(0-1)GPH ❑ B.DAILY VISUAL MONITORING ❑ 9.BIENNIAL INTEGRITY TEST(0.1)GPH SECONDARILY CONTAINED PIPING SECONDARILY CONTAINED PIPING PRESSURIZED PIPING(Cheek all that apply): PRESSURIZED PIPING(Check all that apply): 10.CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL 10.ALCONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL ALARMS AND(Chakme7 ALARMS AND(Chekwc) ❑ a.AUTO PUMP SHUT OFF WHEN A LEAK OCCURS vl�wftO PUMP SHUT OFF WHEN A LEAK OCCURS ❑b.AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM ❑b.AUTO PUMP S14UT 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 F112.ANNUAL INTEGRITY TEST(0.1 GPR) E] 12.ANNUAL INTEGRITY TEST(0.1 GTN) SUCTION/GRAVITY SYSTEM SUCTION/GRAVITY CONTINUOUS SYSTEM ❑ 13.CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS ❑ 13.CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS EMERGENCY GENERATORS ONLY(Chale 910wt appy) EMERGENCY GENERATORS ONLY(Check as 14.CONTINUOUS SUMP SENSOR IQUT A AUTO PUMP SHUSU spy) SHUTOFT ❑ CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF• AUDIBLE AND VISUAL ALARMS AUDIBLE AND VISUAL ALARMS I❑ S.AUTOMATIC LIN E LEAK DETECTOR(3.0 GPH TEST)WDOUT FLOW II5.AUTOMATIC LE LEAK DETECTOR(3.0 GPH TEST)W ITHO T 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 468 ❑ 2 CONTINUOUS DISPENSER PAN SENSOR+AUDIBLE AND VISUAL ALARMS ❑ 5.TRENCH LINER/MONITORING Q n ❑ 3CONTINUOUS DISPENSER PAN SENSOR W�AUTO SHUT OFF FOR ❑ 6.NONE -On" . 469 � DISPENSER+AUDIBLE AND VISUAL ALARMS OWNER/OPERATOR SIGNATURE I ardfydw the mfwnudanP dedhvemIII and ac,al a0ahceoray Iedge 4 470 -- SIGNATURE OF OWNEILOPERATOR DATE NAME OF OWNER/OPERATOR(print TIME OF OWNER/OPERAT n2 11- n. A(rtf e71 .. NN�` Pm Apprmed(Fmkal°ee°alY) 4]4 Pemut EVharim Delc(Fml°rel°scmy) 475 Pemot Nmcbae wy) 673 EE0003804 12/31/2003 PT00020102013 UPCF(12/99 revised)