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FROM: J. Schetter PHONE NO. : 5306667692 Dec. 02 2005 02:46PM PG U1 IFiED PROGRAM CONSOLIDATED FORM- TANKSXISI I M4 UNDERGROUND STORAGE TANKS - TANK PAGE 2 Page z of z VL PIPING COWI*R(JCTION(Clwck all that I ) UNDERGROUND PIPING AROVEGROUND PIPING SY.ITF.M TYPE, ® 1.PRESSURE ❑2,SUCTION ❑3.GRAVITY 458. ❑1.PRESSURE ❑2.SUCffON ❑3.CRAVITY 419. CONSTRUCTION/ ❑1.SINGLE,WALL 0 3.LINED TRENCH ❑99.01IiFu( 460. ❑1.SINGLE WAI.j. Q 95.UNKNOWN 462, 1.1ANIIFAC!'URLrR 2.DOUBLE WALL ❑95.UNKNOWN ❑2.DOUBLE WALL ❑99.OTHE)( J MANUFACTURER AA_ Smith 461. MANUFACTURER 163. ❑ t.BARE STEEL ❑6 FRP COMPATIBLE W/100 METHANOL ❑1.BARE STEEL. ❑6.FRP COMPATIBLE W/I00%METHANOL 2.STAINt.P.SS STEEL ❑7.GALVANIZED STEED ❑2,STAINI_P.SS STPEL ❑7.GALVANIZED STEfI. ❑3.PLASTIC COMPATIBLE WITH CONTENTS ❑95.UNKNOWN 03.PLASTIC COMPATIBLE;W/CONTENTS [18.FiAXTRI.F.(MDPP.) ❑99.OTHER ®4.FIBERGLASS p 8.FLEXIBLE(HDPE) ❑W.OTHER ❑4.FIBERGLASS ❑9.CATHODIC PROTECT ION ❑5,STEEL W/COATING ❑9.CATHODIC PROTECTION 464. CI 5,STEEL W/COATING ❑95.UNKNOWN 405. Vii.PIPING LEAK DETI:C-MiO (C'ncca mimat (A de wrip-tion of the monitoring nm shalt he aohinitted to ttr locfl o p UNDERGROUND PIPING ABOVEGROUND PIPING SINGLE WALL PIPING 466. SINGLE WALL PiPiNG 467. PRESSURIZED PIPING(Chock oll tbat apply): PRESSURIZED PIPING(Check Ml that apply): ❑1. ELECTRONIC LINE LEAK DETECTOR 3.0 GPM TEST WITH AU-I'0 PUMP [31. ELECTRONIC LINE LEAK DETECTOR 3.0 GPI-1-Es-r W('1'H AUTO PUMP SMUT-OFF FOR LEAK,SYSTEM FAILURE,AND SYSTEM DISCONNEC'T10N SHUT OFF FOR LEAK,SYSTEM FAILURE,AND SYSTEM DISCONNECTION +AUDIBLE AND VISUAL ALARMS, +AUi)IRT.F,"AND VISUAL ALARMS. ❑2. MONTHLY 0,2 GPH TEST ❑2. MONTHLY 0.2 GPI-TEST Q 3, ANNUAL IN'rEGRUTY TEST(0.1 GPH) ❑3. ANNUAL INTEGRITY TEST(0.1 GPN) ❑4, DAILY VISUAL CHECK CONVENTIONAL SOC11ON SYSTEMS CONVENTIONAL SUCTION SYSTEMS(Check all that apply) ❑5. DAiLY VISUAL MONITORING OP PUMPING SYSTEM+TRIENNIAL PIPING INTEGRITY TEST(0.1 GPH) L15. DAILY VISUAL MONITORING OP PIPING AND PUMPINGSYS"TEM SAFE SUCTION SYSTEMS(NO VALVES IN BELOW 0ROVND PIPING): ❑6. TRIENNIAL INTEGRITY TEST(0.1 GPH) ❑7. SELF MON17'ORIN(' 3AFF SUCTION SVSTRMS(NO VALVES IN BELOW GROUND PIPING). GRAVI"IY BLOW ❑7. SELF MONITORING [19. BTFNNIAI.TNT PGRITY TEST(0.1 GPH) GRAVITY PLOW(Chock all that apply): 08, DAILY VISUAL MONITORING [19. Rll:.NNIAI.1rri-E(GRiTY T.ES'r(0.T GPH) SECONDARILY CONTAINED PIPING SECONDARILY CONTAINED PIPING PRESSURIZED PIPING(Check RA that Rpply): PRF;W]RIZIC13 PIPING(Chock all that apply)T 10, CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL 10. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VTSTIAL ALARMN AND(Check one) ALARMS AND(Check one) ❑a. AUTO I'UW 91rUr OFF WHEN A LEAK OCCURS ❑s AUTO PUMP SHUT OFF WHEN A LEAK OCCURS ®b. AUTO PUMP SHUT or-T.FOR LEAKS,SYSTEM FATI:URE AND SYSTEM ❑b. AUTO IYUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM DISCONNECTION DISCONNECTION ❑c. NO AUTO PUMP SHUT OFF ❑c. NO AUTO PUMP SL1U T OFF ®11. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)WT T H PLOW SHUT ❑ 11. AUTOMATIC LEAK Der T,C1'OR OFF OR RESTRICTION Q 12, ANNUAL INTEGRITY TEST(0.1 GPM) ❑12. ANNUAL INTEGRITY TEST(0.1 GPH) SUCTION/GRAVITY SYSTEM SUCTION/GRAVITY SYSTEM ❑13. CONTINUOUS SUMP SENSOR AtJDIRLF AND VISUAL ALARMS ❑13. CONTINUOUS SUMP SENSOR*AUDI-SLE AND VISUAL ALARMS EMERGENCY GENERATORS ONLY(Check all that apply) EMERGENCY GENERATORS ONLY(Chock ail that apply) ❑14, CONTINUOUS SUMP SENSOR$=Q-UT AIl"10 PUMP SHUT OFF El 14. CONTINUOUS SUMP SENSOR.WITRQU AUTO PUMP81-111T OFF AUDIBLE AND VISUAL.ALARMS AUDIBLE AND VISUAL ALARMS ❑15. AUTOMATIC LINK LL'AK DETECTOR (3.0 GPH TEST) WiTH0t1T FIA-)W SHUT OFF OR RES'fRJCTIUN El15. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST) 016, ANNUAL INTEGRITY TEST(0.1 GPli) ❑16, ANNUAL INTEGRITY TEST(0.1 GPM) [117. DAILY ViSUAL CIIECK ❑ 17.DAILY VISUAL CHECK VIII.DISPENSER CONTAINMENT DISPENSER CONTAINMENT 46a. r-11. hLOAi-MP:CHANISM-THAT SHUTS OFF SHFAR VALVE. [:14. DAILY VISUAL CHECK 460. DATF.TNSTAI I-HD [12. CONTINUOUS DISPENSER PAN SENSOR+ATJDiBLE AND VIST JAL ALARMS ❑5. TRENCH/LINER MONITORING 1999 0 3. CONTTNTJOUS DTSPFNSFR PAN SENSOR WIT l4 AUTO SHUT OFF FOR ❑f NONE DISPENSER+AUDIBLE AND VISUAL ALARMS IX.OWNER/OPERATOR SiGNAT(TRF, I wrti1'yJOUR)OPURATOR information Provided herein is true and aeeurube to the best of my knowledge, S)GNATO OPE :T0 DATE: 10/12/04 Oro. f �. NAMJi O (Print): John Schetter TiTLs OF OWNER/OPERATOR: COMPhance Specialist d7 Permit Numlxx(Ayettcy use only) 471 Permit APr,r-t By(AT;wncy turn tmly) 474. 1 Permit Expiration Date(Agency use only) 4'n.