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UNIFIED PROGRAM CONSOLIDATED FORM TANKS UNDERGROUND STORAGE TANKS - TANK PAGE 2 va9e Rr ' VL PIPING CONSTRUCTION(Cook an thal appy) UNDERGROUND PIPING ABOVEGROUND PIPINGI SYSTEAITYPE i0 1 PRESSURE 912.SUCTION 0 3. GRAVITY 4S8 I T PRESSURE 0 2. SUCTION ❑ 3. GRAVITY 4591 CONSTRUCIrION1 1 SMIGLEWALL 0 3. LINED TRENCH 099. OTHER 460 10 I. SWGLEWALL 095. UNKNOWN a62� MMLFACTURERI 2 DOUBLE WAU. ❑95. UNKNOWN O 2, DOUBLE W LL 099. OTHER M.WUFACTURER 461 MANUFACTURER asst I.BRAE STEEL 0 4 FRPCOMPATIBLEWI(MMEMANOL0 1. BARESTEEL D S. FRPCOMPATIBLE WI 100%METHANOL MATERIALS AND ID Z STAINLESS STEEL 0 7.GALVANIZED STEEL ❑ 2. STAINLESS STEEL ❑ 7. GALVANIZED STEEL CORROSION PROTECTION U 3. PLASTIC COMPATIBLE WITH CONTENTS _ 095. UH.,. 0 B. PLASTIC COMPATIBLE WITR CONTENTS ❑ 8. FLEXIBLE(HOPE) 099. OTHER 10 4. FIBERGLASS 0 8. FLEXIBLE(HOPE) 099. OTHER D 4. FIBERGLASS ❑ 9. CATHODIC PROTECTION ID S. STEELYRCOATING D 9. CATHODIC PROTECTION 464 .D 5. STEELWICOATING 095. UNKNOWN a65: 'VII.PIPING LEAK DETECTION(Cheek e6tlrat apply)(A descnphon pl the mcri;lvy popzm Brat be submrt.M Di Ne krral a9mry) UNDERGROIINO PO WG ABOVEGROUND PIPING SINGLEWALLPINNG 466 SINGLE WALL PIPING 467; PRESSURIZ PIPING(CAa^_t V Nat appy): PRESSURIZED PIPING(Check all Nat appy): 1. ELECTRONICLINE LEAK DETECTOR JO GPHTESTWTH AUTO PUMP SHUT OFF FOR ❑ 1. ELECTRONIC LINE LEAK DETECTOR GO GPM TEST WTH AUTO PUMP SHUT OFF FOR LEAK LEAK.SYSTEM FAILURE.AND SYSMY.DISCONNECTION•AUDIBLE AND VISUAL SYSTEM FAILURE.AND SYSTEM DISCONNECTION•AUDIBLE AND VISUAL ALARMS M MS ❑ Z. MONTHLY 03 GPH TEST ❑ 2. 610nTNLY02 GPM TEST ❑ ❑ 3 ANNUAL INTEGRITY TEST(0.1 GPM) 3 ANNUAL MIMGRITY TEST(0.1 GPM) ID 4 GAILY VISUAL CHECK ' COSVE.Yr10.vA1 SUCTION SYSTEMS'. CONVE.w ORAL SUCTION SYSTEMS(Check N Nat appy): ❑ 5 DAILY VISUAL MONITORING OF PUMPING SYSTEM.TRIENNIAL' PIPING INTEGRITY 0 5. DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM TEST(0.1 GPM) 0 6. TRIENNIAL INTEGRITY TEST(0.1 GPM) j ::E SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING? SAFE SUCTION SYSTEMS(NO VALV<S IN BELOW GROUND PIPING): � ❑ 7 SELFMONITORING ❑ 7. SELFKION90MN'G GRAVITY FLOW i GRAVITY FLOW(C�ck a9 Wt apply): ❑ 5 BIENNIAL M17E�GRIr1'TEST III 1 GPM) ❑ 8. OALYVISUAI.MONITORING 0 9 BIENNIAL INTEGRITY TEST(0.1 GPM) SECONDARILY CONTAINED PIPING SECONDARILY CONTAINED PIPING %R2SSURIZED PIPING(Check aR Nat appy) PRESSURIZED PIPING(Check uTrhat apply): 10. CONTINUOUS TURBINE SUMP SENSOR WITHAUDIBLE AND VISUAL ALARMS AND (Cyet ) 10. CONTINUOUS TURBINE SUMP SENSORLMTN AUDIBLE AND VISVPL AIARMSAND(drtek Ma)! 0 a. AUTO PUMP SHUT OFF VMEN A LEAK OCCURS 0 a. AUTOPUMPSHUTOFFVMENALEAKOCCURS 0 L AUrO PUMP SHUTOFF FOR LEAKS.SYSTEM FAILURE AND SYSTEM 0 b. AUTO PUMP SHUT OFF FOR LEAKS.SYSTEM FAILURE AND SYSTEM DISCONNECTION i DISCONNECTION D c NO AUTO PUMP SHUT OFF ❑ c NO AUTO PUMP SHUT OFF ' ❑ IA omAnC LINE LEAK DETECTOR(30 GPM TEST)WITH FLOW SHUT OFF OR I❑ 11. AUTOMATIC LEAK DETECTOR i RESTRICTION GPM) 012 C3 12.ANHUALINTEGRITYTEST(OAGPH) . ANNUAL INTEGRITY TEST(0.1 SUCTIOWGRAVRY SYSTEM: SUCno"RAVrTY SYSTEM: ❑ 13 CONTINUOUS SUMP SENSOR-AURBLEANOMSUALA3ARMS 1013. CONTINOOUS SUMP SENSOR-AUDIBLE ANO VISUA.ALARMS EM ERGENCY GEN ERATORS ONLY(Chepl:al Nat appy) EMERGENCY GENERATORS ONLY(Cft. k Nat appy) D 14, CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF-AUDIBLE AND 1014. CONTINUOUS SUMP SENSOR WITHO AUTO PUMP SHUTOFF•AUDISLEANONSUAL VISUAL ALARMS ALARMS .'015 AUTOMATIC LINE LEAK DETECTOR(3 0 GPM TEST)WTHovr FLOWSHUTOFFOR ID 1S. AUTOMATIC UNE LEAK O ETECTOR(3.0 GPM TEST) RESTRICTION 1013.ANNUAL W'TEGRITY TEST(0.1 GPM] 0 16.ANNUAL INTEGRITY TEST(0.1 GPM) x.017. DAILY VISUAL CHECK 017. DALYVISUALCHECK VRLDISPENSER CONTAINMENT >{ DISPENSERCONTADB•IENT ❑ I. FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE 0 A. DAILY VISUAL CHECK DATE INSTALLED 46B ❑ 2. CONTINUOUS DISPENSER PAN SENSOR-AUDIBLE AND VISUAL ALARMS 0 S.TRENCH LINER IMON90RING _ ❑ 3. CONTINUOUS DISPENSER PAN SENSORWTH AUTO SHUT OFF FOR DISPENSER•AUDIBLE AND VISUAL ALARMS 0 6.NONE 469 i (IXOWNER)OPERATORSIGNATURE I .«Hormalim prw9.4her ' 41, BIM lab 91e Des:M my kVylECye. SIG EOFO RIOPE 0 I DATE © � 470 F OWNS PERAI IPAnU 471 T FOVME P TOR fRA I 1 1 472 htail - \ F PermitNinbei(Fa kcL vu anty) 473 j PeMt ApprwW ft JIoearusaaYy) 474 I Perm]E IatYafl Date(Fr.bcar use arKyl 475 I UPCF(1199 revised) 7 Formerly SNIRCS Form B VVW