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NIFIED PROGRAM CONSOLIDATED FORM TANKS UNDERGROUND STORAGE TANKS -TANK PAGE 2 VI.PIPING CONSTRUCTION(Check eY HMl appy) UNDERGROUND PIPING ABOVEGROUND PIPING SYSTEM TYPE 1 PRESSURE ❑ 2. SUCTION ❑ J. GRAVITY ❑ 1. PRESSURE ❑ 2. SUCTION ❑ J. GRAVITY CONSTRUCTION/ ❑ 1 SINGLE WALL �J. LINED TRENCH ❑99. OTHER F11. SINGLE WALL ❑85. UNKNOWN 11MANUFACTURER 2. fX)UBLE WALL 95. UNKNOWN ❑ 2. DOUBLE WALL 1199 OTHER MANUFACTURER MANUFACTURER ❑ 1.BARE STEEL ❑ S. FRP COMPATIBLE W/IDD%METHANOL ❑ 1. BARE STEEL ❑ B. FRP COMPATIBLEW/100%METHANOL MATERIALS AND ❑ 2. STAINLESS STEEL ❑ T.GALVANIZED STEEL ❑ 2. STAINLESS STEEL ❑ T.GALVANIZED STEEL CORROSION PROTECTION ❑ 0. PLASTIC COMPATIBLE WITH CONTENTS 1195. UNKNOWN ❑ J. PLASTIC COMPATIBLE WITH CONTENTS ❑ 8. FLE)(IBLE(HOPE) 099. OTHER �4. FIBERGLASS ❑ 8. FLEXIBLE(HOPE) 0 9. OTHER. ❑ 4. FIBERGLASS ❑ e. CATHODIC PROTECTION ❑ 5. STEELW/COATING ❑ 9. CATHODIC PROTECTION ❑ 5. STEELWICOATING 1195. UNKNOWN VIL PIPING LEAK DETECTION(Check aA Mat eppW UNDERGROUND PIPING ABOVEGROUND PIPING SINGLE WALL PIPING SINGLE WALL PIPING PRESSURIZED PIPING(CMck 0 that apply: PRESSURIZED PIPING(Check all Mat apply): ❑ 1. ELECTRONIC LINE LEAK DETECTOR 3.0 GPM TEST WITH AUTO PUMP SHUT OFF FOR ❑ 1. ELECTRONIC LINE LEAK DETECTOR 3.0 GPM TEST WITH AUTO PUMP SHUT OFF FOR LEAK. LEAK SYSTEM FAILURE.AND SYSTEM DISCONNECTION•AUDIBLE AND VISUAL SYSTEM FAILURE,AND SYSTEM DISCONNECTION;-AUDIBLE AND VISUAL ALARMS ALARMS ONTHL ❑ 2. MONTHLY 0.2 GPM TEST ❑ 2. MONTHLYTEGITYPM TESEST ❑ ]. ANNUAL INTEGRITY TEST IDA GPM) ❑ J.ANNUAL INTEGRITY TEST(0.1 GPM) ❑ 4, DAILY VISUAL CHECK - CONVENTIONAL SUCTION SYSTEMS: CONVENTIONAL SUCTION SYSTEMS(CMck All that appy): ❑ 5. DAILY VISUAL MONITORING OF PUMPING SYSTEM-TRIENNIAL PIPING INTEGRITY ❑ 5. DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM TEST III I GPM) ❑ B. TRIENNIAL INTEGRITY TEST KI GPM) SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING) SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): ❑ T. SELFMONITORING ❑ ]. SELFMONITORING GRAVITY FLOW GRAVITY FLOW(Check aA IMt apply): ❑ 9. BIENNIAL INTEGRITY TEST III I GPM) ❑ 8. DAILY VISUAL MONITORING ❑ 9 BIENNIAL INTEGRITY TEST(0 1 GPM) SECONDARILY CONTAINED PIPING SECONDARILY CONTAINED PIPING PRESSURIZED PIPING(Chock aft that appy): PRESSURIZED PIPING(Chock e8 that appy): 10. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL ALARMS AND (Check one) 10.CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL ALARMS AND(check One) ❑ a. AUTO PUMP SHUT OFF WHEN A LEAK OCCURS ❑ e. AUTO PUMP SHUT OFF WHEN A LEAK OCCURS ❑ 0 AUTO PUMP SHUT OFF FOR LEAKS.SYSTEM FAILURE AND SYSTEM ❑ p_ 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(J.0 GPM TEST)VATH FLOW SHUT OFF OR ❑ RESTRICTION It. AUTOMATICLEAK DETECTOR 12. ANNUAL INTEGRITY TEST(0.1 GPM) ❑ 12.ANNUAL INTEGRITY TEST(0.1 GPM) GUCTIONIGRAVITY SYSTEM. SUCTION/GRAVITY SYSTEM: ❑ 10. CONTINUOUS SUMP SENSOR,AUDIBLE AND VISUAL ALARMS ❑ 13. CONTINUOUS SUMP SENSOR•AUDIBLE AND VISUAL ALARMS EMERGENCY GENERATORS ONLY(Check as that appy) EMERGENCY GENERATORS ONLY(Clack all 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)W TROUT FLOW SHUT OFF OR ❑ 15. AUTOMATIC LINE LEAK DETECTOR(J.0 GPM TEST) RESTRICTION ❑ 18.ANNUAL INTEGRITY TEST(0 1 GPM) ❑ 18. ANNUAL INTEGRITY TEST(0.1 GPM) ❑ 9. DAILY VISUAL CHECK ❑ 17. DAILY VISUAL CHECK VIII.DISPENSER CONTAINMENT DISPENSER CONTAINMENT ❑ 1. FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE ❑ 4. DAILY VISUAL CHECK OATEINSTALLED ❑ 2. CONTINUOUS DISPENSER PAN SENSOR•AUDIBLE AND VISUAL ALARMS ❑ 5. TRENCH LINER I MONITORING ❑ J.CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR DISPENSER-AUDIBLE AND VISUAL ALARMS ❑ 8. NONE DL.OWNERIOPERATOR SIGNATURE I ceNy Mal Me intormalmn P.vldad penin ie Wa and accuraU to Ma bait Of my 0ovdad9e. SIGNATUREOFOVMER/OPERATOR DATE NAME OF OWNERIOPERATO /pMf) TITLE OF OVMERIOPERATOR Permit NOnWO(Fohwal uta ooayl Pelmil Appmved(ForMcal me oay) Psm Elp"Wn Data lFor twal uae ON,) CUPAFORM(4199) Formerly SVJRCB Form 3