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UNIFIED PROGRAM CONSOLIDATED FORM TANKS UNDERGROUND STORAGE TANKS -TANK PAGE 2 Ya e of '.Z- VL LVL PIPING CONSTRUCTION(that all that apply) UNDERGROUND PIPING ABOVEGROUND PIPING SYSTEM TYPE ®1.PRESSURE ❑2.SUCTION ❑3.GRAVITY ass ❑ 1.PRESSURE ❑2.SUCTION ❑3.GRAVITY 459 CONSTRUCTION/ ❑1.SINGLE WALL ❑3.LINED TRENCH ❑99.OTHER 460. ❑1.SINGLE WALL ❑95.UNKNOWN 462 MANUFACTURER 12 2.DOUBLE WALL ❑95.UNKNOWN ❑2.DOUBLE WALL ❑99.OTHER MANUFACTURER S rn ,T W 461. 1 MANUFACTURER 463. ❑1.BARE STEEL ❑6.FRP COMPATIBLE W/100`/o METHANOL ❑1.BARE STEEL El 6.FRP COMPATIBLE W/100%METHANOI, ❑2.STAINLESS STEEL ❑7.GALVANIZED STEEL ❑2.STAINLESS STEEL ❑7.GALVANIZED STEEL ❑3.PLASTIC COMPATIBLE WITH CONTENTS ❑95.UNKNOWN ❑3.PLASTIC COMPATIBLE W/CONTENTS ❑g.FLEXIBLE(HDPE) ❑99.OTHER ®4.FIBERGLASS ❑g.FLEXIBLE(HDPE) ❑99.OTHER ❑4.FIBERGLASS ❑9.CATHODIC PROTECTION ❑5_STEEL W/COATING ❑9.CATHODIC PROTECTION 464. 1 ❑5.STEEL W/COATING ❑95.UNKNOWN 465 VM PIPING LEAK DETECTION(check all that apply)(A 'tion otthe monitoring propam shall be sabmeted to the local ag=W.) UNDERGROUND PIPING ABOVEGROUND PIPING SINGLE WALL PIPING 466. SINGLE WALL PIPING 467 PRESSURIZED PIPING(Check all that apply): PRESSURIZED PIPING(Check all that apply): ❑1. ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WII AUTO PUMP ❑1. ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP SHUT-OFF FOR LEAK,SYSTEM FAILURE,AND SYSTEM DISCONNECTION SHUT OFF FOR LEAK,SYSTEM F.AULURE,AND SYSTEM DISCONNECTION +AUDIBLE AND VISUAL ALARMS. +AUDIBLE AND VISUAL ALARMS. ❑2. MONTHLY 0.2 GPH TEST [12. MONTHLY 0.2 GPH TEST ❑3_ ANNUAL INTEGRnT TEST(0.1 GPH) ❑3. ANNUAL INTEGP=TEST(0.1 GPM) ❑4. DAFLY VISUAL CHECK CONVEN ZONAL SUCTION SYSTEMS CONVENTIONAL SUCTION SYSTEMS(Check all that apply) ❑5. DAILY VISUAL MONITORING OF PUMPING SYSTEM+TRIENNIAL PIPING ❑5. DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM INTEGRITY TEST(0.1 GPH) SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): [36. TRmNNIAL INTEGRrrY TEST(0.1 GPH) ❑7. SELF MONITORING SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): GRAVITY FLOW ❑7. SELF MONITORING E39. BIENNIAL INTEGRITY TEST(0.1 GPH) GRAVITY FLAW(Check all that apply): ❑S. 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 W1T AUDIBLE AND VISUAL 10. CONTINUOUS TURBINE SUMP SENSOR WITTI AUDIBLE AND VISUAL ALARMS AND(Check one) ALARMS AND(Check one) 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 S 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 INI I. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST) FLOW SHUT ®11.AUTOMATIC LEAK DETECTOR OFF OR RESTRICTION ❑12. ANNUAL INTEGRITY TEST(0.1 GPH) ❑12. ANNUAL INTEGRITY TEST(0.1 GPH) SUCTION/GRAVITY SYSTEM SUCTION/GRAVITY SYSTEM ❑13. CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS ❑13.CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS EMERGENCY GENERATORS ONLY(Check all that apply) EMERGENCY GENERATORS ONLY(Check all that apply) [114. CONTINUOUS SUMP SENSOR WITH AUTO PUMP SHUT OFF ❑14. CONTINUOUS SUMP SENSOR WITH AUTO PUMP SHUT OFF AUDIBLE AND VISUAL ALARMS AUDIBLE AND VISUAL ALARMS 1315. AUTOMATIC LINE LEAK DETECTOR (3.0 GPH TEST) WITHOUT FLOW ❑15.AUTOMATIC LINE LEAKDETECrOR(3.0 GPH TEST) SHUT OFF OR RESTRICTION ❑16. ANNUAL INTEGRITY TEST(0.1 GPH) ❑16.ANNUAL INTEGRrrY TEST(0.1 GPH) ❑17. DAILY VISUAL CHECK ❑17.DAILY VISUAL CHECK VIII.DISPENSER CONTAINMENT DISPENSER CONTAINMENT 468. [11. FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE [14. DAILY VISUAL CHECK 469. DATE INSTALLED E2, CONTINUOUS DISPENSER PAN SENSOR+AUDIBLE AND VISUAL ALARMS [15. TRENC HILINER MONITORING [13. CONTINUOUS DISPENSER PAN SENSOR WjTH AUTO SHUT OFF FOR [16. NONE 1 Q Z DISPENSER+AUDIBLE AND VISUAL ALARMS DL OWNER/OPERATOR SIGNATURE I certify that the information provided herein is true and accurate to the best of my knowledge. SIGNATURE OF OWNEWOPERATOR L 0 "N 2 C E L'-T @ 5 470' AD NAME OF OWNER/OPERATOR(print): C L`S E Cv Z t1n c-D rZ S S TITLE OF OWNER/OPERATOR L L YE G G' X1.5 ��L472. w QE a Permit N=nber(AFncy use only) 473 1 Permit Approved By(Agency use only) 474. 1 Permit Expiration Date(Agency use only) a75.