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NIFIEO PROGRAM CONSOLIDATED F , I TANKS UNDERGROUND STORAGE TANKS - TANK PAGE 2 ;I A.PIPING CONSTRUCTION(Check ad mat aopy) I UNCEPGRCUND PIPING j ABOVEGPCUNO PIPING SYSTE.'.L^IPE ❑ oPESSURE SUCTION ❑ 3. GRAVITY!❑ �aESS:)RE ?. 31,;C7CN ❑ 3. GRAVITY CONSTRUCTION/ ❑ / SINGLE'NALL 3 UNEO TRENCH U 99. 'OTHER ❑ 1. SINGL_'NALL L"35. UNKNOWN MANUFACTURER ❑ 2. OOUBLE'NALL ❑95. UNKNOWN ❑ Z OCUBLEWALL 99. OTHER j MANUFACTURER MANUFACTURER J 1.BARE STEEL ❑ 3 RP COMP4TIBLE`N/100%METHANOL ❑ 1. BARE STEEL '� 3. FRP COMPATIBLE'N!'DO%METHANOL MA7cRIALS AND ❑ 2. STAINLESS STEEL I_: 7. GALVANIZED STEEL ❑ Z STAINLESS STEEL ❑ 7. GALVANIZED STEEL CORROSION PROTECT ION ❑ 3. PLASTIC COMPATIBLE'M7H CONTENTS ❑95. JNKNOWN ❑ 3. MASTIC COMPATIBLE`MTH CONTENTS ❑ 3. =LEXIBLE;MOPE_) ❑ 19. OTHER ❑ s. FIBERGLASS ❑ 3. FLEXIBLE(HOPE) :199. OTHER ❑ A FIBERGLASS 77 9. 17HOOIC PROTECTION ❑ 5. STEEL'N/COATING IJ 9. CATHODIC PROTECTION ❑ 5. 3 7SEL N/COATING ❑95. UNKNOWN VII.PIPING LEAK DETECTION(0vcK ad mat aoW) JNDERGROUND PIPING j ABOVEGROUNO PIPING SINGLE WALL PIPING SINGLE WALL PIPING PRESSURIZED PIPING(Check all mat an^: PRESSURIZED PIPING iQ'ecK ad that appy): ❑ ELECTRONIC UNE'LAK OETECTCR 3.0 GPM TEST MATH AUTO PUMP SHUT OFF FOR ❑ 1. ELECTRONIC UNE LEAK DETECTOR 3.0 GPM-EST'MTH AUTO PUMP SHUT OFF FOR LEAK. LEAK.SYSTEM FAILURE..AND SYSTEM OISCONNECTON+AUDIBLE AND VISUAL SYSTEM FAILURE AND SYSTEM DISCONNECTION-;AUDIBLE AND VISUAL ALARMS ALARMS ❑ L MONTHLY 0.2 GPM TEST ❑ Z. MONTHLY 0.2 GPM TEST ❑ 3. ANNUAL INTEGRITY TEST(O.t GPM) ❑ 3. ANNUAL INTEGRITY TEST(0.1 GPM) I❑ t. GAILY VISUAL CHECK CCNV ENTIONAL SUCTION SYSTEMS: CONVENTIONAL SUC70N SYSTEMS)Check as mat ao^: ❑ 5. DAILY VISUAL MONITORING OF PUMPING SYSTEM-TRIENNIAL PIPING INTEGRITY I❑ 5- DAILY VISUAL MONITORING OF PIPING AND PUMPING SYS i EM FEST(0.1 GPM) I❑ 3. 7RIENNAL INTEGRITY EST X0.1 GPM) i SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): I SAFE SUCTION SYSTEMS tNO VALVES IN BELOW GROUND PIPING): ❑ - 3EL=MONITORING ❑ 7. 3ELF MONITORING GRAVITY FLOW' i GRAVITY FLOW(Check as mat aopM: i❑ ). 31ENNIAL INTEGRITY-EST(0.1 GPM) I❑ 3. DAILY VISUAL.MCNITCRING ❑ 3. 31ENNiAL:NTEGRIT--FST(O.1GPH) SECONDARILY CONTAINED PIPING SECONDARILY CONTAINED PIPING PRESSURIZED PIPING iChecK all mar aoptv): PRESSURIZED PIPING!G'Ieor ad that ao^: '0. 'ONTI NUOUS TURBINE SUMP SENSOR MTH AUDIBLE AND VISUAL ALARMS AND Cheuc ones '0.OONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL ALARMS AND(cnecx one) ❑ a. AUTO PUMP SHUT OFF`MIEN A LEAK OCCURS ❑ a. AUTO PUMP SHUT OFF WHEN A LEAK OCCURS o. AUTO PUMP SHUT OFF FOR-.=AKS.SYSTEM FAILURE AND SYSTEM j DISCONNECTION J o. AUTO PUMP SHUT OFF FOR LEAKS,3Y5 i cM FAILURE AND SYSTEM$TFl�OISCONNEC-ION c. NO AUTO PUMP SHUT OFF ❑ = VO AUTO PUMP SHUT OFF ❑ 'i. AUTOMATIC UNE LEAK DETECTOR(3.0 GPM 7EST)WITH FLOW SHUT OFF OR ❑ 11. AUTOMATIC LEAK OE-ECTOR .RESTRICTION ❑ '2. ANNUAL INTEGRITY TEST(0.1 GPM) ❑ 12. ANNUAL INTEGRITY EST!0.1 GPM) j SUCTION/GRAVITY SYSTEM: SUCTIONIGRAVITY SYSTEM: ❑ 13. CONTINUOUS SUMP SENSOR-AUDIBLE AND VISUAL ALARMS ❑ 13. CONTINUOUS SUMP SENSOR-AUDIBLE AND VISUAL ALARMS EMERGENCY GENERATORS ONLY(C.hecK as that apply) EMERGENCY GENERATORS ONLY IC1.as mat a00" ❑ 14 CONTINUOUS SUMP SENSOR`MTHOUT AUTO PUMP SHUT OFF-.AUDIBLE AND ❑ 14. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF-AUDIBLE AND VISUAL VISUAL ALARMS ALARMS ❑ -5. AUTOMATIC UNE LEAK DETECTOR(3.0 GPM TESTI WITHOUT FLAW SHUT OFF OR ❑ 15. AUTOMATIC UNE LEAK DETECTOR(3.0 GPM TEST) RESTRICTION ❑ '8. .ANNUAL INTEGRITY`EST(0.1 GPH) ❑ 16. ANNUAL 1NTEGRITY-EST(0.1 GPM) ❑ .7. DAILY VISUAL CHECK ❑ 17 DAILY VISUAL CHECK VIII.DISPENSER CONTAINMENT DISPENSER CONTAINMENT ❑ 1. FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE El A. DAILY VISUAL CHECK OATE INSTAL-D ❑ 2. CONTINUOUS DISPENSER PAN SENSOR-AUDIBLE AND VISUALALARMS Ll 5- TRENCH LINER/MONITORING ❑ 3. CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR DISPENSER-AUDIBLE ANO VISUAL ALARMS ❑ 3. NONE IX.OWNER/OPERATOR SIGNATURE cemN lnat me information bnovfbad nereKl rs:rue anb accwate to the nest of my Knbwleage. SIGNATURE OF OWNER/CPERATCR DATE � I .NAME OF OWNER/OPERATOR ipnm) 7rTI.Z-OF-WNER/OPSRATCR 'Inrrt Number)For focal use only/ 3x I Aoomveb fForfoCal use omv) ?�nnrt 8coratron Cale)For row/use bnry) I ! j CLIPAFORM!a/99) Formerly SWRCS Form B