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UNIFIED PROGRAM CONSOLIDATED FORM TANKS UNDERGROUND STORAGE TANKS-TANK PAGE 2 Vi.PIPING CONSTRUCTION on that Pae_of UNDERGROUND PIPING ABOVEGROUND PIPING SYSTEM TYPE .PRESSURE ❑2.SUCTION H.3,GRAVITY 458 ❑1.PRESSURE ❑2. SUCTION ❑3.GRAVITY 4% CONSTRUCTION ❑1.SINGLE WALL ❑3.LINED TRENCH ❑99.OTHER am ❑1.SINGLE WALL ❑95.UNKNOWN 462 MANUPAC11MER DOUBLE WALL ❑95.UNKNOWN ❑2.DOUBLE WALL El 99.OTHER ' MANUFACTURER 1q, Q. C y- �_ 461 MANUFACTURER 463 ❑1.BARE STEEL ❑6.FRP COMPATIBLE w/100% aallr[ NOL ❑1.BARE STEEL 0.6.FRP COMPATIBLE Wll o MMHuNOL ❑2.STAINLESS STEEL ❑7.GALVANIZED STEEL ❑Unb 0 [12. STAINLESS STEEL [17.GALVANIZED STEEL [13.PLASTIC COMPATIBLE W/CONTENTS _ O 99. 005a ❑3. PLASTIC COMPATIBLE W/CONTENTS [3S.FLEMLE(HOPE) ❑99. OTHER *,('FIBERGLASS ❑S.FLEXIBLE(HDPE) ❑4. FIBERGLASS ❑9.CATHODIC PROTECTION [15.STEEL W/COATING [19 CATHODIC PROTECTION 464 ❑5. STEEL W/COATING ❑95.UNKNOWN 465 VIL PIPING LEAKDETECTION Check a0 that A fthe A-11 be athmaW a thatotal .) UNDERGROUND PIPING ABOVEGROUND PIPING SINGLE WALL PIPING - 456 SINGLE WALL PIPING *7 PRESSURIZED PIPING(Cbxk all that appy): PRESSURIZED PIPING(Cb-3 m dw appy): ❑1.ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST MM AUTO PUMP SHUT ❑L ELECTRONIC LINE LEAK DETECTOR 3.0 OPH TEST 9'fIF3 AUTO PUMP 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. ❑2.MONTHLY 0.2 OPH TEST ❑2. MONTHLY 02 GPH TEST ❑3.ANNUAL INTEGRITY TEST(0.1 GPH) ❑3.ANNUAL INTEGRITY TEST(0.1GPH) ❑4. DAILY VISUAL CHECK CONVENTIONAL SUCTION SYSTEMS CONVENTIONAL SUCTION SYSTEMS(Check an that apply) ❑5.DAILY VISUAL MONITORING OF PUMPING SYSTEM+TRIENNIAL PIPING C3 5. DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM INTEGRITY TEST(0.1 GPT) SAFE SUCTION SYSTEMS(NO VALUES IN BELOW GROUNDPIPING): ❑6. TRIENNIAL INTEGRITY TEST(0.1 GPH) ❑7-SELF MONITORING SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): GRAVITY FLOW [17. SELF MONITORING ❑9.BSNNIAL INTEGRITY TEST(0.1 GPI) GRAVITY FLOW(Cbeck.0 th Vpl,):* ❑S. DAILY VISUAL MONITORING ❑9. BIENNIAL INTEGRITY TEST(0.1 GPH) SECONDARILY C014TAINED PIPING SECONDARILY CONTAINED PIPING PRESSURIZED PIPING(Cbvk.0 that apply): PRESSURIZED PIPING(Chock all dw apply): 10. CONTINUOUS TURBINE SUMP SENSOR MM AUDIBLE AND VISUAL 10. CONTINUOUS TURBINE SUMP SENSOR MM AUDIBLE AND VISUAL ALARMS AND(Cheek om) ALARMS AND(Chock or) Ma, AUTO PUMP SHUT OFF WHENA LEAK OCCURS ®a AUTO PUMP SHUT OFF WHEN A LEAK OCCURS JR b. AUTO FUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM 10 b AUTO PUMP STRUT 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)-MM FLOW SHUT ®11. AUTOMATIC LEAK DETECTOR OFF OR RESTRICTION [312. ANNUAL INTEGRITY TEST(0.1 GPH) ❑12. ANNUAL INTEGRITY TEST(0.1 GPH) SUCTIOMNRAVIY SYSTEM SUCTIONGRAVITY SYSTEM 13. CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS ❑13. CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS EMERGENCY GENERATORS ONLY(Clank.31 that appy) EMERGENCY GENERATORS ONLY(Cb W that appy) ❑14. CONTINUOUS SUMP SENSOR WITH AUTO PULS SHUT OFF• ❑14. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP STRUT OFF• AUDIBLE AND VISUAL ALARMS AUDIBLE AND VISUAL ALARMS ❑15. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)WITHOUT FLOW [115. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST) SHUT'OFF OR RESTRICTION ❑16.ANNUAL INTEGRITY TEST(0.1 GPH) ❑ 16.ANNUAL INTEGRITY TEST(0.1 GPIs) ❑17. DAILY VISUAL CHECK ❑17. DAILY VISUAL CHECK VUL DISPENSER CONTAINMENT DISPENSER CONTAINMENT 1.FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE ❑4.DAILY VISUAL CHECK DATE I7STALLBB ❑2.CONTINUOUS DISPENSER PAN SENSOR+AUDIBLE AND VISUAL ALARMS t35.TRENCH LINER/MONITORING `/ 3.CONTINUOUS DISPENSER PAN SENSOR M3 AUTO SHUT OFF FOR ❑6.NONE 469 DISPENSER+AUDIBLE AND VISUAL ALARMS DL OWNERIOPERATOR SIGNATURE Iw+tiy Nat is mat..d atavataa tha bander,kmaAdf SIG A �O TOR / DATE 470 �o 5 , 1 6 - NAME OFO PRTOR(PnM) /�G 431 TITLE OF OWNER/OPERATOR 4n Patma h har(Fwbduma at*) In Perch ApptoaadlfmloWuataay) 474 Pxphrim Dw(Fm local uat ocy) 4n