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tA UNIFIED PROGRAM CONSOLIDATED FORM TANKS UNDERGROUND STORAGE TANKS -TANK PAGE 2 VL PIPING CONSTRUCTION IGeck as Matappy) UNDERGROUND PIPING ABOVEGROUND PIPING SYSTEM TYPE 1 PRESSURE ❑ Z. SUCTION ❑ ]. GRAVITY ❑ 1. PRESSURE ❑ Z. SUCTION ❑ 0. GRAVITY CONSTRUCTIONN, ❑ 1. SINGLE WALL ❑ ]. LINED TRENCH ❑99. OTHER ❑ 1. SINGLE WALL 1195 UNKNOWN MANUFACTURER. 2 DOUBLE WALL �] (J'��95.{�INKNONRJ ❑ Z. DOUSLE WALL ❑99. OTHER MANUFACTURER q C ] MAT MANUFACTURER ❑ I.BARE STEEL ❑ e. FRP COMPATIBLE W/100%METHANOL ❑ 1. BARE STEEL ❑ B. FRP COMPATIBLE W/100%METHANOL MATERIALS AND ❑ 2. STAINLESS STEEL Eli. GLVANIZEO STEEL 132. STAINLESS STEEL CORROSION ❑ T. GALVANIZED STEEL PROTECTION ❑ ]. PLASTIC COMPATIBLE WATH CONTENTS 11 9S. UNKNOWN ❑ ]. PLASTIC COMPATIBLE KITH CONTENTS Cl e. FLEKIBLE(HDPE) ❑99. OTHER 4. FIBERGLASS ❑ e. FLEKIBLE(HOPE) ❑99. OTHER ❑ A FISERGLASS ❑ 9. CATHODIC PROTECTION ❑ 5 STEEL W1 COATING ❑ 9. CATHODIC PROTECTION ❑ 5. STEEL W/COATNG 1195. UNKNOWN VII.PIPING LEAK DETECTION(Chackaa Matappy) UNDERGROUND PIPING ABOVEGROUND PIPING SINGLE WALL PIPING SINGLE WALL PIPING PRESSURIZED PIPING fCneck ap Mar apply): PRESSURIZED PIPING(CAx#a9 Met appy): ❑ I. ELECTRONIC LINE LEAK DETECTOR]O GPM TEST WITH AUTO PUMP SHUT OFF FOR ❑ 1. ELECTRONIC UNE LEAK DETECTOR OO GPM TEST WITH AUTO PUMP SHUT OFF FOR LEAK, LEAK,SYSTEM FAILURE.AND SYSTEM DISCONNECTION•AUDIBLE AND VISUAL SYSTEM FAILURE.AND SYSTEM DISCONNECTION;AUDIBLE AND VISUAL ALARMS ALARMS IMONTHLY 0.2 GPM TEST ❑ 2. MONTHLY 02 GPM TEST ❑ . ❑ 11 ]. ANNUAL INTEGRITY TEST(0.1 GPM)]. ANNUAL INTEGRITY TEST(0.1 GPM) ❑ 4. DAILY VISUAL CHECK CONVENTIONAL SUCTION S'/STEMS: CONVENTIONAL SUCTION SYSTEMS(Clack M Mar appy): ❑ S. DAILY VISUAL MONITORING OF PUMPING SYSTEM•TRIENNIAL PIPING INTEGRITY ❑ S. DAILY VISUAL MONITORING OF PIPING AND PUMPINGSYSTEM TEST to GPM) ❑ e. TRIENNIAL INTEGRITY TEST IDA GPM) SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING)'. SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): ❑ T. SELFMONITORING ❑ T. $EIf MONITORING GRAVITY FLOW! GRAVITY FLOW(Chock 0 Mat apply): ❑ 9 BIENNIAL INTEGRITY TEST IO I GPM) ❑ e. DAILYVISUALMOWTORING ❑ 9. BIENNIAL INTEGRITY TEST(0 1 GPM) SECONDARILY CONTAINED PRESSURIZED PIPING(Clack IPING N Mat appy): SECONDARILY CONTAINED PIPING PRESSURIZED PIPING(Chock as Mar appy): 10 CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL ALARMS AND (Gneck one) 10.CONTINUOUS TURBINE SUMP SENSOR KITH AUDIBLE AND VISUAL ALARMS AND(check om) El •. AUTO PUMP SHUTOFF WHEN A LEAK OCCURS ❑ a. AUTO PUMP SHIT OFF WHEN A LEAK OCCURS ❑ 5 V AUTOPUMP OFF FOR LEAN$.SYSTEM FAILURE AND SYSTEM EC11p AUKS TO PUMP SHUT OFF FOR LEA ,SYSTEM FAILURE AMC)SYSTEM DISCONNECTION 0UTOMP SHU ❑ c NOAUTO PUMP SHUTOFF ❑ o NOAUTOPUMPSHUTOFF 11 AUTOMATIC LINE LEAK DETECTOR(3.0 GPM TEST)WITH FLOW SHUT OFF OR RESTRICTION ❑'iI. AUTOMATIC LEAK DETECTOR ❑ 12. ANNUAL INTEGRITY TEST(0 1 GPM) ❑ 12. ANNUAL INTEGRITY TEST(0.1 GPH) SUCTIOWGRAVITY SYSTEM. SUCTION/GRAVITY SYSTEM. ❑ 13 CONTINUOUS SUMP SENSOR•AUDIBLE AND VISUALAIARMS ❑ 13. CONTINUOUS SUMP SENSOR•AUDIBLE AND VISUAL ALARMS EMERGENCY GENERATORS ONLY(Chock as Mal appy) EMERGENCY GENERATORS ONLY(Chock as Mal appA ❑ 14. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF•AU01BLE AND ❑ 14 CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF•AUDIBLE AND VISUAL VISUAL ALARMS ALARMS - ❑ 15. AUTOMATIC LINE LEAK DETECTOR 13.0 GPM TEST)WITHOUT FLOW SHUT OFF OR ❑ 15.AUTOMATIC LINE LEAK DETECTOR(].0 GPM TEST) RESTRICTION ❑ le. ANNUAL INTEGRITY TEST(0.1 GPM) ❑ Ie, ANNUAL INTEGRITY MST(0.1 GPM) ❑ li. DAILYVISUALCHECK ❑ 17. DAILY VISUAL CHECK VIII.DISPENSER CONTAINMENT DISPENSER CONTAINMENT 'M 1. FLOAT MECHANISM THAT SHIFTS OFF SHEAR VALVE ❑ 4. DAILY VISUAL CHECK DAM E INSTALLED ❑ Z. CONTINUOUS DISPENSER PAN SENSOR•AUO(SI,E AND VISUAL A1-AWS ❑ 5. TRENCH LINER/MONITORING ❑ 3. NTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR DISPENSER•AUDIBLE AND VISUAL ALARMS ❑! NONE UL OWNER/OPERATOR SIGNATURE I rack!,Mat Me inMmawn lain is u wt vM aGltat.to Me WNW mY Ihvafae9a. SIGNATOR OF OWNER/OPE T GTE„ NAME FOWNER/ ERATOR(PMO TITLE OF OWNEMOPERATOR PNmit NumSar(Forlaal uaa or9Y1 Panni[APprevap fFa Taal uaa aV)'1 P4cm4 Eapaaeon Dau fForleca/we orgy) CUPAFORM(4199) Formed SYVRCB Form B