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wIFIED PROGRAM CONSOLIDATED FOR*0�151l Dl TANK: TA0198406 PR#: PR0231984 I�I A FAC#: 1393 A000 UNDERGROUND STORAGE TANKS - TANK PAGE 2 Y� or'7 VI.PIPING CONSTRUCTION(Chem all wt apply> Page 990 UNDERGROUND PIPING ABOVEGROUND PIPING SYSTEM TYPE ❑ I.PRESSURE ❑ 2.SUCTION ❑ 3.GRAVITY 458 ❑ I.PRESSURE ❑ 2.SUCTION ❑3.GRAVITY 459 CONSTRUCTION ❑1.SINGLE WALL ❑3.LMEDTRENCH ❑ 99.OTHER 460 ❑ L SINGLE WALL ❑ 95.UNKNOWN 463 El 2.DOUBLE WAIL ❑95.UNKNOWN El 2.DOUBLE WALL ❑99.OTHER MANUFACTURER mI MANUFACTURER 463 ❑ 1.BARE STEEL ❑6.FRP COMPATIBLE w/Io9%METHANOL ❑ 1.BARE STEEL ❑ 6.FRP COMPATIBLE w/IN%METHANOL ❑2.STAINLESS STEEL ❑ 7.GALVANIZED STEEL [12.STAINLESS STEEL ❑ 7.GALVANIZED STEEL ❑PLASTIC COMPATIBLEW/CONTENTS ❑ 95.UNKNOWN ❑ PLASTIC COMPATIBLE W/CONTENTS ❑ 95.UNKNOWN [:14.FIBERGLASS ❑ 8.FLEXIBLE(HDPE) ❑ 99.OTHER ❑ 4.FIBERGLASS ❑ 8.FLEXIBLE(HDPE) ❑ 99.OTHER ❑ 5.STEEL W/COATING ❑ 9.CATHODIC PROTECTION 464 ❑ 5.STEEL W/COATING ❑9.CATHODIC PROTECTION 465 VII.PIPING LEAK DETECTION(Cheek all thaI apply)(A mceiplionoftbcnwNtoring pm®am shall besubminM to Nebel aewcy) UNDERGROUND PIPING ABOVEGROUND PIPING SINGLE WALL PIPING 466 SINGLE WALL PIPING 467 PRESSURIZED PIPING(Check all that apply): PRESSURIZED PIPING(Check all that apply): ❑ L ELECTRONIC LME LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP SHUT OFF ❑ 1.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) ❑ 5.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(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 ❑ 9.BIENNIAL INTEGRITY TEST(0.1)GPH GRAVITY FLOW(Check all that apply): ❑ 8.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(Cheek wee) ALARMS AND(Check ww) ❑ 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 SHUT OFF ❑ C.NO AUTO PUMP SHUT OFF ❑ IL 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 SUCITON/GRAVITY SYSTEM ❑ 13.CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS ❑ 13.CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS EMERGENCY GENERATORS ONLY(Click all wt apply) EMERGENCY GENERATORS ONLY(Chem an that apply) ❑ 14.CONTINUOUS SUMP SENSOR WITHOU AUTO PUMP SHUT OFF e ❑ 14.CONTINUOUS SUMP SENSOR WITHO AUTO PUMP SHUT OFF" AUDIBLE AND VISUAL ALARMS AUDIBLE AND VISUAL ALARMS ❑ 15.AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)WITHT 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 VIII.DISPENSER CONTAINMENT DISPENSER CONTAIN HENT ❑ 1.FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE ❑ 4.DAILY VISUAL CHECK DATEINSTALLED 4682.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 UL.OWNERIOPERATOR SIGNATURE I unify wI Ne Wonwtionpmvid ha<inu aucaadafcuesw towbmt 9fmykeewledge. SIGNATURE OF OWNER/OPERATOR DATE 470 NAME OF OWNER/OPERATOR(print) TITLE OF OWNER/OPERATOR 4]I 472 PpmitNwNm(Fw IocaIucconly) 473 P=it Appmo1(Farkca1oeonly) 474 Pmmt Expiration Dal.(For l Iuse only) 475 PT0001390 EE0000817 12/31/2003 UPCF(12/99 revised)