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• • q 11(7toeL 2os UNIFIED PROGRAM CONSOLIDATED FORM TANKS UNDERGROUND STORAGE TANKS - TA 2 l��z-7 .. UNDERGROUND_ CSI-RIkINGCONSTRUCTION Chakiahn Pa a of PIPING SYSTEM TYPE 01.PRESSURE 02.SUCTION ABOVEGROUND PIPING CONSTRUCTION/ 1.SINGLE WALL 0 3 03,GRAVITY 95e. 0 1.PRESSURE ❑2.SVCI70N Ll 3.cRAvlrr 939. MANUFACTURER .LINED TRENCH ❑99,OTHER 460. ❑'1.SINGLE WALL 0 2.DOUBLE WALL 0 95.UNKNOWN D 95.UNKNOWN 462 MANUFACTURER 0 2.DOUBLE WALL 0 99.OTHER ❑I.BARESTEEL 0 6.FRP COMPATIBLE W/100Ye MM74ANOL .461. MANUFACTURER ❑1.BARE STEEL 463. ❑2.STAINLESS STEEL ❑7.GALVANIZED STEEL 0 6.FRF COMPATIBLE W/100%METHANOL 03.PLASTIC COMPATIBLE WITH CONTENTS �y�(/ ❑2.STAINLESS STEEL 0 7.GALVANIZED STEEL 0 4.FIBERGLASS 0 95' 0 3.PLASTIC BERGL COMPATIBLE W/CONTENTS ❑8,FLEXIBLE(HDPE) 0 99.OTHER ❑8.FLEXIBLE(HDPE) ❑99,OTHER (]q,FIBERGLASS 0 5.STEEL W/COATING 0 g CATHODIC PROTECTION 464 0 9.CATHODIC PROTECTION VII.PIPING LEA _ ❑5.STEEL W/COATING 0 95.UNKNOWN DETECTION tlt,.iimu i.;Anand um o[thafroykumm a 465. SINGLE WALL PIPING UNDERGROUND PIPMG .m 4haCnesahmmed c me ldul ABOVEGROUND PIPMG PRESSURIZED PIPING(Check W theta1 466' SINGLE WALL PIPING pp y): [[// PRESSURIZED PIPING(Check all that apply): 461. '0 1. ELECTRONIC LINE LEAK DETECTOR 3.0 OPH TESTWITH AUTO PUMP SHUT-OFF FOR LEAK,SYSTEM FAILURE,AND SYSTEM DISCONNECTION 01, ELECTRONIC LINE LEAK DETECTOR 3.0 OPH TEST WITH AUTO PUMP +AUDIBLE AND VISUAL ALARMS, - SHUT OFF FOR LEAK,SYSTEM FAILURE,AND SYSTEM DISCONNECTION 112. MONTHLY 0.2 GPH TEST .- +AUDIBLE AND VISUAL ALARMS, D 3. ANNUAL INTEGRITY TEST(0.l GPH) [12. MONTHLY 0.2 GPH TEST [13. ANNUAL INTEGRITY TEST(0.1 GPH) CONVENTIONAL.SUCTION SYSTEMS 04, DAILY VISUAL CHECK ❑5. DAILY VISUAL MONITORING OF PUMPING SYSTEM+ CONVENTIONAL SUCTION SYSTEMS(Check all that apply) INTEGRITY TEST(0.1 GPH) TRIENNIAL PIPING 05. DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): [16. TRIENNIAL INTEGRITY TEST(0.1 GPH) 137. SELF MONITORING GRAVITY FLOW SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): 09. BIENNIAL INTEORTfY TEST(0,I GPIs) 07. SELF MONITORING GRAVITY FLOW(Check all that apply): 08- DAILY VISUAL MONITORING SECONDARILY CONTAINED PIPING 09. BIENNIA'INTEGRrrY TEST(0.]GPH) PRESSURIZED PIPING(Check all that apply). SECONDARILY CONTAINED PIPING ' 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(Check one) D a. AUTO PUMP SHUT OFF WHEN A LEAK OCCURS ALARMS AND(Check one) D b.AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM 0 a. AUTO PUMP SHUT OFF WHEN A LEAK OCCURS DISCONNECTION 0 b.AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM Ik NO AUTO PUMPSHUT OFF DISCONNECTION ❑ 11. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)WITHFLOW SHUT Ek NO AUTO PUMP SHUT OFF OFF OR RESTRICTION 0 11.AUTOMATIC LEAK DETECTOR ❑12. ANNUAL INTEGRITY TEST(0.1 GPH) SUCTION/GRAVITY SYSTEM 0 12.ANNUAL INTEGRITY TEST(0.1 GPH) ❑I3. CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS SUCTION/GRAVITY SYSTEM [1EMERGENCY13. CCONTINUOUS GENERATORS NSORONLY(Cheek all Neta 1 D 13.CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS D 14, CONTINUOUS SUMP SENSOR O y) EMERGENCY GENERATORS ONLY(Check all that apply) AUDIBLE AND VISUAL ALARMS �AUTO PUMPSHUTOFF D 14. CONTINUOUS SUMP SENSOR WI PTY) 015. AUTOMATIC LINE LEAK DETECTOR 3.0 GPH TES W AUDIBLE AND VISUAL ALARMS PUMP SHUT OFF SHUT OFF OR RESTRICTION ( T) UT FLOW ❑15. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST) CI 16. ANNUAL INTEGRITY TEST(O.I GPH) ' [117. DAILY VISUAL CHECK 016 ANNUAL INTEGRITY TEST(0.1 GPH) ❑17. DAILY VISUAL CHECK DISPENSER CONTAINMEM- ase. VII OOPENSER CONTAINIDIEI9T.':, - - T0 1. FLOAT MECHANISM THAT SHV I S OFF SHEAR VALVE DATE MSTA Lq [12. CONTINUOUS DISPENSER PAN SENSOR+AUDIBLE AND VISUAL ALARMS D5. . LY MONITORING DAILY VISUAL CHECK 469. 03. CONTINUOUS DISPENSER PAN SENSOR W El55. 1 AUTO SHUT OFF FOR 0 6 NONE ,. DISPENSER+AUDIBLE AND VISUAL ALARMS IN.OWNER/OPERATOR SIGNATURE'. I certify that the information A d he to is hue and c to to the best of my knowledge. SIGNATURE OF OWNER/OP DATE: �2 o NAME OFOWNER/OPERATOR /A) TITLE OF OWN OPERATOR: 45F.- ------- 12.PermitN (Agency use only) 473. Permit Approved BY(Agency use only) 474. Permit Expiation Date(Ageoey use odY) 415. UPCF hwfwrc-b(W9).314 http;//www,unidoesorg Rev,02/16/00