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NIFIED PROGRAM CONSOLIDATED FORM TANKS UNDERGROUND STORAGE TANKS - TANK PAGE 2 VI.PIPING CONSTRUCTION(ChackaNthafappy) UNDERGROUND PIPING ABOVEGROUND PIPING SYSTEM TYPE ❑ 1 PRESSURE SUCTION ❑ 3. GRAVITY ❑ 1. PRESSURE ❑ 2. SUCTION ❑ 3. GRAVITY CONSTRUCTION) . SINGLE WALL ❑ 3. UNEDTRENCH ❑99. OTHER ❑ 1. SINGLE WALL 1195. UNKNOWN MANUFACTURER ❑ Z DOUBLE WALL ❑95. UNKNOWN ❑ 2. DOUBLE WALL 1199, OTHER MANUFACTURER MANUFACTURER BARE STEEL ❑ 6. FRP COMPATIBLE WI 103%METHANOL ❑ 1. BARESTEEL ❑ 5. FRP COMPATIBLE W/1M%METHANOL MATERIALSAND ❑ 2. STAINLESS STEEL ❑ T.GALVANIZEDSTEEL ❑ Z STAINLESS STEEL ❑ y. GALVANIZED STEEL CORROSION 11PROTECTION 3, PLASTIC COMPATIBLE KITH CONTENTS 1195. UNKNOWN 113. PLASTIC COMPATIBLE WITH CONTENTS ❑ 8. FLEXIBLE(HDPE) - 1199. OTHER ❑ 4. FIBERGLASS ❑ B. FLEXIBLE(HDPE) 1191 OTHER ❑ q. FIBERGLASS ❑ 9. CATHODIC PROTECTION ❑ 5. STEEL Wi COATING ❑ 9. CATHODIC PROTECTION ❑ 5. STEEL W/COATING 1195. UNKNOWN VII.PIPING LEAK DETECTION(CMKk ad Met appy) UNDERGROUND PIPING ABOVEGROUND PIPING SINGLE WALL PIPING SINGLE WALL PIPING PRESSURIZED PIPING(CMck all that apply).' PRESSURIZED PIPING(Check aN Mt appy): - ❑ 1. ELECTRONIC LINE LEAK DETECTOR 3.0 GPM TEST NTH AUTO PUMP SHUT OFF FOR ❑ 1. ELECTRONIC LINE LEAK DETECTOR 3.0 GPM TEST WITH AUTO PUMP SHUTOFF FOR LEAK, LEAK,SYSTEM FAILURE,AND SYSTEM DISCONNECTION+AUDIBLE AND VISUAL SYSTEM FAILURE,AND SYSTEM DISCONNECTION;AUDIBLE AND VISUAL ALARMS ALARMS ❑ 2. MONTHLY 0.2 GPM TEST ❑ 2.MONTHLY 02GPH TEST ❑ 3. ANNUAL INTEGRITY TEST(O.t GPM) ❑ 3.ANNUAL INTEGRITY TEST(0.1 GPH) ❑ 4. DAILYVISUALCHECK CONVENTIONAL SUCTION SYSTEMS: CONVENTIONAL SUCTION SYSTEMS(Chock ad that appy): ❑ 5. DAILY VISUAL MONITORING OF PUMPING SYSTEM+TRIENNIAL PIPING INTEGRITY ❑ S. DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM TEST(0,1 GPM) ❑ 6. TRIENNIAL INTEGRITY TEST D 1 GPM) SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): ❑ y. SELF MONITORING ❑ T. SELF MONITORING GRAVITY FLOW GRAVITY FLOW(Check aN therappt): ❑ 9. BIENNIAL INTEGRITY TEST(0 1 GPM) ❑ B. DAILY VISUAL MONITORING ❑ S. BIENNIAL INTEGRITY TEST(0.1 GPM) SECONDARILY CONTAINED PIPING SECONDARILY CONTAINED PIPING PRESSURIZED PIPING(Chock aN that appy): PRESSURIZED PIPING(Check eN that apply): 10. CONTINUOUS TURBINE SUMP SENSOR NTHAUDIBLE AND VISUAL ALARMS AND (Chask ane) 10.CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL ALARMS AND(:heck one) ❑ a. AUTO PUMP SHUT OFF WHEN A LEAK OCCURS ❑ a. AUTO PUMP SHUT OFF MEN A LEAK OCCURS ❑ b. AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM DISCONNECTION ❑ b, AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM DISCONNECTION ❑ t NO AUTO PUMP SHUT OFF ❑ c. NO AUTO PUMP SHUT OFF ❑ 11.AUTOMATIC LINE LEAK DETECTOR(3.0 GPM TEST)WITH FLOW SHUT OFF OR ❑ 11. AUTOMATIC LEAK OETECTOR RESTRICTION ❑ 12.ANNUAL INTEGRITY TEST(0.1 GPM) ❑ 12. ANNUAL INTEGRITY TEST KA GPM) SUCTIONIGRAVITY SYSTEM: SUCTION/GRAVITY SYSTEM: ❑ 13. CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS ❑ 13. CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS EMERGENCY GENERATORS ONLY(Check ad that appy) EMERGENCY GENERATORS ONLY(CMck a#that apply) ❑ 14.CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF+AUDIBLE AND ❑ 14, CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF+AUDIBLE AND VISUAL VISUALALARMS ALARMS ❑ 15.AUTOMATIC LINE LEAK DETECTOR(3,0 GPM TEST)WITHOUT FLOWSHUT OFF OR ❑ 15. AUTOMATIC LINE LEAK DETECTOR(3.0 GPM TEST) RESTRICTION ❑ 16.ANNUAL INTEGRITY TEST IDA GPM) ❑ 16. ANNUAL INTEGRITY TEST(0,1 GPM) ❑ 17. DAILY VISUAL CHECK ❑ 17. DAILY VISUAL CHECK VNh DISPENSER CONTAINMENT DISPENSER CONTAINMENT ❑ 1. FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE ❑ 4. DAILY VISUAL CHECK DATE INSTALLED ❑ 2. CONTINUOUS DISPENSER PAN SENSOR+AUDIBLE AND VISUAL ALARMS ❑ 5. TRENCH LINER I MONITORING ❑ 3. CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR DISPENSER+AUDIBLE AND VISUAL ALARMS B. NONE IX OWNER/OPERATOR SIGNATURE I carliy Nat Ne Inforri proMMad herein is due and a¢urate W Ne best of my bnaMed9e. SIGNATURE OF OWNER/OPERATOR PATE NAME OF OWNER/OPERATOR(I TITLE OF OWNER:OPERATOR Permit Number(For War use onto Permit Appmyed(For latest uss only) Partn6 Eepiradan Data IF.,Mi use any) CUPAFORM(4199) Formedy SVVRCB Form B