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• f <br /> ...��' )TNT ,P PROC.R AM(`ONC(Ii.IT)ATRI)F()RRi <br /> TANkS <br /> UNDERGROUND STORAGE TANKS - TANK PAGE 2 Pae of <br /> VI.PIPING CONSTRUCTION(Check an that zwlr) ABOVEGROUND PIPING <br /> UNDERGROUND PIPING 459. <br /> SYSTEM TYPE ❑1.PRESSURE $.� SUCTION ❑3.GRAVITY 458 ❑1.PRESSURE ❑2.SUCTION ❑3.C'��Y 462. <br /> CONSTRUCTION/ SINGLE WALL ❑3.LINED TRENCH ❑99.OTHER 46o. ❑1.SINGLE WALL [195.UNKNOWN <br /> ❑2.DOUBLE WALL ❑99.OTHER <br /> MANUFACTURER ❑2.DOUBLE WALL ❑95.UNKNOWN 463. <br /> 461 MANUFACTURER <br /> MANUFACTURER 1.BARE STEEL ❑6.FRP COMPATIBLE W/100!METHANOL <br /> (BARE STEEL ❑6.FRP COMPATIBLE W/100%METHANOL 0 2.STAINLESS STEEL ❑7.GALVANIZED STEEL <br /> ❑2.STAINLESS STEEL ❑7.GALVANIZED STEEL 8.FLEXIBLE <br /> ❑3,PLASTIC COMPATIBLE WITH CONTENTS ❑95'UNKNOWN ❑3.PLASTIC 4.FIBERGLAS COMPATIBLE W/CONTE' a 9.CATHODIC PROTECTION ❑M19 <br /> OTHE <br /> ❑4.FIBERGLASS ❑8.FLEXIBLE(HDPE) ❑99.OTHER ❑ ❑95.UNKNOWN <br /> s65- <br /> a6a. ❑5.STEEL W/COATL�G <br /> ❑5.STEEL W/COATING ❑9.CATHODIC PROTECTION shall be suhacd to the local agency,) <br /> VII.PIPI11 NG LEAK DETECTION(Check all that apply)(A description of the=nhwias pmt m <br /> ABO EGROUND PIPING <br /> UNDERGROUND PIPING 467. <br /> 466. SINGLE WALL PIPING <br /> SINGLE WALL PIPING PRESSURIZED PIPING(Check all that apply): <br /> PRESSURIZED PIPING(Check all that apply): <br /> ELECTRONIC ❑1 LEAK <br /> DETECTOR 3.0 GEC <br /> ❑1. SSCTOR3.0 GPH TEST WITH AUTO P SHUT FOR LEAK, YSTEM FAILURE, SYSTEMDISCONNECTION <br /> SHUT-OFF FOR LEAK, TEM AND SYSTEM <br /> +AUDIBLE A*1D VISUAL ALARMS. <br /> +AUDIBLE AND VISUAL ALARMS. ❑2 MONTHLY 0.2 GPH TEST <br /> ❑2. MONTHLY 0.2 GPH TEST <br /> ❑3. A\tiUAL L�-TEGRITI'TEST(0.1 GPH) <br /> [33, ANNUAL INTEGRITY TEST(0.1 GPH) ❑4. DULY VISUAL CHECK <br /> CONVENTIONA1.SUCTION'SYSTEMS(Check all that apply) <br /> CONVENTIONAL SUCTION SYSTEMS <br /> ❑5. DAILY VISUAL MONITORING OF PUMPING SYSTEM+TRIENNIAL PIPING D� <br /> ❑S. DAILY VISUAL MONTTORG OF PIPING AND PUMPING SYSTEM <br /> INTEGRITY TEST(0.1 GPH) ❑6. TRIEN'N1AL INTEGRITY TEST(0.1 GPH) <br /> SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): <br /> SELF MONITORING <br /> ❑7. SELF MOXITORING <br /> f9.o <br /> VITY FLOW <br /> GRAVITY FLOW(Check all that apply): <br /> BIENNIAL INTEGRITY TEST(0.1 GPH) DAILYVISUAL MONTTORLNG <br /> ❑9. BIE`INIAL INTEGRITY TEST(0.1 GPH) <br /> SECONDARILY CONTAINED PIPING <br /> SECONDARILY CONTAINED PIPING PRESSURIZED PIPING(Check all that apply): <br /> PRESSURIZED PIPING(Check all that apply): <br /> 10. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL 10. SOAR S OUD(eckooze)SUMP SENSOR WITH AUDIBLE AND VISUAL <br /> ALARMS AND(Check one) ❑a. ALTO PUMP SHUT OFF WHEN A LEAK OCCURS <br /> J3 a. AUTO PUMP SHUT OFF WHEN A LEAK OCCURS b. ALTO PLti>P SHIT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM <br /> ❑b. AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM ❑ <br /> DISCONNECTION <br /> DISCONNECTION ❑c NO AUTO PUMP SHUT OFF <br /> ❑c. NO AUTO PUMP SHUT OFF <br /> ❑11. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)WITH FLOW SHUT ❑I 1 AUTOMATIC LEAK DETECTOR <br /> OFF OR RESTRICTION ❑12.ANNUAL INTEGRITY TEST(0.1 GPH) <br /> ❑12. ANNUAL INTEGRITY TEST(0.1 GPH) SUCTION/GRAVITY SYSTEM <br /> SUCTION/GRAVITY SYSTEM <br /> 13. CONLN' <br /> TUOUS SUyIP SENSOR+AUDIBLE AND VISUAL ALARM <br /> ❑13. CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS EMERGENCY <br /> ERGENCY GENERATORS ONLY(Check all that apply) <br /> EMERGENCY GENERATORS ONLY(Check all that apply) CO;v"TLNUOUS SUMP SENSOR WITHO AUTO PUMP SHUT OFF <br /> [:)14. CONTINUOUS SUMP SENSOR WITH AUTO PUMP SHUT OFF 014. AUDIBLE AND VISUAL ALARMS <br /> AUDIBLE AND VISUAL ALARMS <br /> ❑15. AUTOMATIC LINE LEAK DETECTOR (3.0 GPH TEST) WITHO FLOW ❑15. AUTOMATIC LLti°E LEAK DETECTOR(3.0 GPH TEST) <br /> SHUT OFF OR RESTRICTION ❑16 A2rNUAL INTEGRITY TEST(0.1 GPH) <br /> C]16. ANNUAL INTEGRITY TEST(0.1 GPH) ❑17.DAILY VISUAL CHECK <br /> ❑17. DAILY VISUAL CHECK <br /> VIII.DISPENSER COriTAINNIENT ❑4. DAILY VISUAL CHECK 469. <br /> DISPENSER CONTAINMENT 468_ []1. FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE <br /> DATE INSTALLED ❑2. CONTINUOUS DISPENSER PAN SENSOR*AUDIBLE A`'D VISUAL ALARMS ❑S. TRENCH/LINER MONITORING <br /> n� [13. CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR ❑6. NONE <br /> (� DISPENSER+AUDIBLE AND VISUAL ALARNIS <br /> IX.OWNERIOPERATOR SIGNATURE <br /> 1 certify th the information provided ein is true and accurate to the best of my knowledge. j/ 470. <br /> SI A E OF OWNE O R DATE' ZO B y <br /> AME 472. <br /> V F ER/OP O �/��J TI E OF ON'KER/OP TO , <br /> t) 'L <br /> 6 4� rut Expiration Date(Agency use only) 475. <br /> Pcnni er um (Agency use only) Permit Approve y(Agency a only) 'ett <br /> { Rev.02/16/00 <br /> http:/Iwww.unidocs.org �✓ <br />