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FROM : J. Schetter PHONE NO. : 5306667692 Dec. 02 2005 02:45PM P4 CWIFIED PROGRAM CONSOLIDATFI) FOiZ tWl TANKS Ex-I�-1/N 4 UNDERGROUND STORAGE TANKS- TANK PAGE 2 Pa•C z of z V t.PIPING CONSTRUCT]ON(C)eck a0 that appy) UNDERGROUND PIPING I ABOVEGROUND PIPING SYSTEM TYPLr ®1,PRESSURE [12.SUCTION 3.(9RAV1'1'Y alit. [] 1.PRESSURE; ❑2.SUCTION ❑3.GRAVITY 459. CONSTRUCTION/ ❑I_SINGLE WALL [1 T 3.LINEDR6NCII L]99.OTHER 460 ❑1.SINGLE WALL E]95.UNKNOWN 462. MANUFACTURER M 2.DO[JI31.E WALL E_]95.1TNKNOWN ❑2,DOUBLE WALL ❑99.OTFIISR MAN`UFACTIJRER A.O. Smith 461. MANUFACTURER 463. ❑1.AARP.STEEL ❑6.FRP COMPATIBLE W/100"/6 METHANOL [11.BARE STEEL ❑6.FRP COMPATITILE W/100%METHANOL ❑2.STAINLESS STL•FU ❑7.GALVANIZED STLPl. ❑2.STAINLESS STEEL ❑7.GAI•vANIZED STEEL ❑3 PLASTIC COMPATIRLC W)i'g CONTENTS ❑95.UNKNOWN [11.PLASTIC COMPATIIII.E W/CONTENTS ❑8.I,LEXIBLE(HDPE.) ❑99.OTHER M 4.FISCRGI.ASS ❑8.FLGXTBL.F,(HDPE) [199.OTHER (]4,FIBERGLASS ❑9.CATHODIC PROTEC'T'ION ❑5.STFFI,W/COATING [19.CATHODIC PROTECTION 464. ❑5.STEEL W/COATING ❑95.UNKNOWN 445. VII.PIPING LEAK DETECTION(Check all tl,m y t (A iptim or the monitoring program stall Dc wbokival to Ilm local agency.) UNDERGROUND PIPING ABOVr:GROUND PIPING SINGLE WALL PIPING 466 SINGLE WALL PIPING 467, PRESSURIZED PIPING(Check all that apply) PRF..SSURIZED PIPING(Chock all that apply): 111. ELECTRONIC LINE LEAK .DETECTOR 3.0 GPH TEST WITH AUTO PUMP [11. I1LTsC7ROtl7C LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP SHUT-0FF FOR LEAK,SYSTEM FAILURE,AND SYSTEM DISCONNF.(.TTON SHUT OFF FOR LEAK,SYSTEM FAILURE,AND SYSTEM DISCONNECTION +AUDIBLE AND V ISUAL ALARMS. +AUDIBLE AND VISUAL ALARMS. ❑2. MONTHLY 0.2 GPH TEST [12. MONTIiLY 0.2 GPI)TEST [13. ANNIIAI,INTEGRITY TEST(0.I GPH) ❑3. ANNUAL INTEGRITY TPST(0,1 GPH) [34. DAILY VISUAL CRECK CONVENTIONAL SUCTION SYSTEMS CONVENTIONAL SUCTION SYSTEMS(Check all that apply) [IS- DAILY VISUAL MONITORING OF PUMPING SYSTEM+TRIENNIAL PIPING INTEC R.11Y TEST(0.1 GPH) ❑5. DAILY VTSIJAl.MONITORING OF PIPING AND PUMPING SYSTEM SAFE MICT[ON SYSTEMS(NO VALVES IN 517I.OW GROUND PIPING): 06, TRIENNIAL INTEGRITY TEST(0.1 OKI) L17. SELF MONITORING SAVE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): GRAVITY FLOW E]7. SSI.F MONITORING ❑9. BTENNTAI.INTP,GRITY TFS'r(0.1 GPF1) GRAVITY FLAW(Chock all that apply): []8. DATLYVISUAI/MONITORING [39. BIENNIAL:INTEGRITY TEST(0.1 GPH) SECONDARILY CONTAINED PIPING SECONnARILY CONTAINED PIrINC: PRESSURIZED PIPING(Chock all that apply): PRES81IRI7.ED PIPING(Chuck all that apply): 10. CONTINUOUS TURBINE SUMP SENSOR WN 1.1 AUDIBLE AND VISUAL 10. CONTINUOUS TURBINE SUMP SENSOR WIT AUDIBLE AND VISUAL ALARMS AND(Cluck one) ALARMS AND(Cluck(ne) ❑a. AUTO PUMP SHUT OFF WHEN A LEAK OCC'.URS ❑a. AUTO 1'IJMP S111J'r Or•F W HrN A 1.PAK OCCURS ®b. AUTO PUMP SHUT OFF FOR LE-AKS,SYSTEM FAIT,URE AND SYSTEM ❑b. AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM DISCONNECTION DISCONNECTION ❑c. NO AUTO PUMP SHUT OFF ❑�. NO AUTO PUMP SHUT OFF M 11. AUTOMATIC LINE LEAK DETECTOR 0,0 GPH TEST)WI FLOW SHUT OPP OR RESTRICTION El]1.AUTOMATIC LEAK DETECTOR ❑12. ANNIIAI,INTEGRITY TEST(0.1 GPH) ❑12. ANNUAL INTEGRITY TEST(0,1 GPH) SUCTION/GRAVITY SYSTEM SUCTION/CRAVITY SYSTEM ❑13. CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS ❑13, CONTINUOUS SUMP SENSOR.1.AUDIBLE AND VISUAL ALARMS EMERGENCY GENERATORS ONLY(Check all that apply) EMERGENCY GENERATOR$ONLY(Check ail that apply) [114. CONTINUOUS SUMP SENSOR}7'WVS AUTO PUMP SHUT OFF ❑14. CONTINUOUS SUMP SENSOR WITHOUT AUTO PI,1MP SHUT OFF AUDIBLE AND VISUAL ALARMS AUDIBI.F,AND VISUAL ALARMS E)15, AUTOMATIC LINE LEAK I)VTF,CTOR (3.0 GPH TEST) JIT FLO SHUT OFF OR RESTRICTION W ❑15 AUTOMATIC LINE LEAK DETECTOR(3.0 GPH 1'ES1� ❑16. ANNUAL INTEGRITY TliS'T(0.1 GPH) ❑16. ANNUAL INTEGRITY TEST(0.1 GPH) ❑17. DAILY VISUAL CHECK []17, DAILY VISUAL CHECK VIIL DISPENSER CONTAINMENT DISPENSER CONTAINMENT 401. ❑ I. FLOAT MECHANISM HIST SHUTS OFF SHEAR VAI_VP. ❑4. DAILY VISUAL CHECK 469. DATE INSTALLED [12. CONTINU011S D1SPF,NS ER PAN S1 NSOR.r AUDIBLE AND VISUAL ALARMS [15. TRENCFT/I.TNPR MONITORING 1999 CO3, CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR ❑6. NONE DISPENSER+AUDIBLE AND VISUAL ALARMS UX.OWNER/OPERATOR SIGNATURE I certify that tqc information provided herein is hue and accurate to the best of my knowledge. SIGNATURE OP T R DATE: 10/12J04 470 NAME OF O R/OPERATOR(print): John Schetter TITLE OF OWN1rR/OPERATOR: Compliance gpeciallSt 471 Permit Number(Agency use only) 47.3 1 Permit Appmv*d By(Azency use only) 414. 1 Pemnit i xpiration Date(Agcnoy use only) 475.