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4 K TIFIRn PROCR A M r0NCni J n A T F n UP- -1 TANKS UNDERGROUND STORAGE TANKS -TANK PAGE 2 Page of VI.PIPING CONSTRUCTION(check au that apply) UNDERGROUND PIPING ABOVEGROUND PIPING SYSTEM TYPE ®1.PRESSURE ❑2.SUCTION ❑3.GRAVITY 458. ❑1.PRESSURE ❑2.SUCTION ❑3.GRAVITY 459. CONSTRUCTION/ ❑1.SINGLE WALL ❑3.LINED TRENCH ❑99.OTHER 460. ❑1.SINGLE WALL ❑95.UNKNOWN 462. MANUFACTURER ®2.DOUBLE WALL ❑95.UNKNOWN ❑2.DOUBLE WALL ❑99.OTHER MANUFACTURER 461. 1 MANUFACTURER 463. [11.BARE STEEL ❑6.FRP COMPATIBLE W/100%METHANOL ❑1.BARE STEEL ❑6.FRP COMPATIBLE W/100%METHANOL ❑2.STAINLESS STEEL ❑7.GALVANIZED STEEL ❑2.STAINLESS STEEL ❑7.GALVANIZED STEEL ❑3.PLASTIC COMPATIBLE WITH CONTENTS ❑95.UNKNOWN ❑3.PLASTIC COMPATIBLE W/CONTENTS ❑8.FLEXIBLE(HDPE) ❑99.OTHER ®4.FIBERGLASS ❑8.FLEXIBLE(HDPE) [199.OTHER ❑4.FIBERGLASS [19.CATHODIC PROTECTION ❑5.STEEL W/COATING ❑9.CATHODIC PROTECTION 464. ❑5.STEEL W/COATING ❑95.UNKNOWN 465. VII.PIPING LEAK DETECTION(check au that y)(A 'pdon ofthe monitoring program shall be submitted to the local .) 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 WITH AUTO PUMP [11. 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 FAILURE,AND SYSTEM DISCONNECTION +AUDIBLE AND VISUAL ALARMS. +AUDIBLE AND VISUAL ALARMS. [12. MONTHLY 0.2 GPH TEST [12. MONTHLY 0.2 GPH TEST [33. ANNUAL INTEGRITY TEST(0.1 GPH) ❑3. ANNUAL INTEGRITY TEST(0.1 GPH) [14. DAILY VISUAL CHECK CONVENTIONAL SUCTION SYSTEMS CONVENTIONAL SUCTION SYSTEMS(Check all that apply) ❑ S. DAILY VISUAL MONITORING OF PUMPING SYSTEM+TRIENNIAL PIPING INTEGRITY TEST(0.1 GPH) [35. DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): [16. TRIENNIAL INTEGRITY TEST(0.1 GPH) ❑7. SELF MONITORING SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): GRAVITY FLOW ❑7. SELF MONITORING [19. BIENNIAL INTEGRITY TEST(0.1 GPH) GRAVITY FLOW(Check all that apply): [18. DAILY VISUAL MONITORING [19. 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 WITH AUDIBLE AND VISUAL 10. CONTINUOUS TURBINE SUMP SENSOR WITH 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 ❑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 ®11. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)WITH FLOW SHUT OFF OR RESTRICTION ❑11.AUTOMATIC LEAK DETECTOR ❑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 [113.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 WITHOUT AUTO PUMP SHUT OFF ❑14. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF AUDIBLE AND VISUAL ALARMS AUDIBLE AND VISUAL ALARMS [115. AUTOMATIC LINE LEAK DETECTOR (3.0 GPH TEST) WITHOUT FLOW ❑ SHUT OFF OR RESTRICTION I5. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST) ❑16. ANNUAL INTEGRITY TEST(0.1 GPH) ❑16.ANNUAL INTEGRITY TEST(0.1 GPH) [317. DAILY VISUAL CHECK ❑17. DAILY VISUAL CHECK VIII.DISPENSER CONTAINMENT DISPENSER CONTAINMENT 468. ❑1. FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE [14. DAILY VISUAL CHECK 469. DATE INSTALLED ❑2. CONTINUOUS DISPENSER PAN SENSOR+AUDIBLE AND VISUAL ALARMS ❑5. TRENCH/LINER MONITORING 1999 ®3. CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR ❑6. NONE DISPENSER+AUDIBLE AND VISUAL ALARMS IX.OWNER/OPERATOR SIGNATURE I certify $at the information provided herein is true and accurate to the best of my knowledge. SIGNA F WNER/ R, DATE:2/21/2003 470, NAMEt� WNER/OPERATOR(print): .1011I1 Schetter TITLE OF OWNER/OPERATOR: Compliance Specialist 47� Permit Number(Agency use only) 473. Permit Approved By(Agency use only) 474. Permit Expiration Date(Agency use only) 475.