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J UNMED PROGRAM CONSOLIDATED FORM TANKS UNDERGROUND STORAGE TANKS-TANK PAGE 2 VL PIPING CONSTRUCTION ChedaO thepap of UNDERGROUND PIPING ABOVEGROUND PIPING SYSTEM TYPE 1.PRESSURE (32.SUCTION 1].3.GRAVT[Y 4541 [31.PRESSURE 132. SUCTION ❑3.GRAVITY es9 CoNSTRUCITON ❑1.SINGLE WALL ❑3.LINED TRENCH 0 99.OTHER 460 ❑1.SINGLE WALL ❑95.UNKNOWN 463 MANUFACIVRHI M 2.DOUBLE WALL ❑95.UNKNOWN ❑2.DOUBLE WALL I]99.OTHER MANUFACTURER 46l MANUFACTURER 463 ❑ I.BARE STEEL ❑6.FRP COMPATIBLE whom MM ANOL ❑1.BARE STEEL ❑6.FRP COMPATIBLE WAM MMOL ❑2.STAINLESS STEEL ❑7.GALVANIZED STEEL ❑Uolmown ❑2. STAINLESS STEEL ❑7.GALVANIZED STEEL ❑3,PId5I[C COMPATIBLE W/CONTENTS - ❑99. OOur ❑3. PLASTIC COMPATIBLE W/CONTENTS ❑8.FLEMBLE(HOPE) ❑99. OT}IDt 4.FBERGLASS ❑S.FLEXIBLE(HOPE) ❑4. FIBERGLASS ❑9.CATHODIC PROTECTION ❑5.STET.W/COATING ❑9.CATHODIC PROTECTION 464 ❑5. STEEL W/COATING ❑95.UNKNOWN 465 VII.PIPING LEAK DETECTION Chert a0 tm A of the nwndonng MW=en.a be memmd m thabd UNDERGROUND PIPING ABOVEGROUND PIPING SINGLE WALL PIPING 466 SINGLE WALL PIPING 467 PRESSURIZED PIPING(Chat W dw apply); PRESSURIZED PIPING(Cant m thK apply): ❑1.ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WIE AUTO PUMP SHUT ❑I. ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST MM 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 GPH TEST ❑2. MONTHLY 0.2 GPH TEST ❑3.ANNUAL INTEGRITY TEST(0.1GPH) [13.ANNUAL INTEGRITY TEST(0.IGPH) ❑4. DAILY VISUAL CHECK CONVENTIONAL SUCTION SYSTEMS CONVENTIONAL SUCTION SYSTEMS(Chert on that apply) ❑5.DAILY VISUAL MONITORING OF PUMPING SYSTEM+TRIENNIAL PIPING 5. DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM INTEGRITY TEST(0.1 GPH) 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 07. SELF MONITORING ❑9.BIENNIAL INTEGRITY TEST(0.1 GPH) GRAVITY FLOW(Cbak.O dw apply): ❑8. DAILY VISUAL MONITORING ❑9. BIENNIAL INTEGRPTY TEST(0.1 GPH) SECONDARILY CONTAINED PIPING SECONDARILY CONTAINED PIPING PRESSURIZED PIPING(Cb k.H tm appy): PRESSURIZED PIPING(Cb k all dw ppy): 10. CONTINUOUS TURBINE SUMP SENSOR MIE AUDIBLE AND VISUAL 10. CONTINUOUS TURBINE SUMP SENSOR ']M AUDIBLE AND VISUAL ALARMSAND(Chrtme) ALARMS AND(Cbsk one) gf-AuTo PUMP SHUT OFF WHEN A LEAK OCCURS ®a AUTO PUMP SHOT OFF WHEN A LEAK OCCURS r'b. AUTO PUMP SENT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM M b AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM DISCONNECTION DISCONNECTION ❑c. NO AUTO PUMP SENT OFF ❑c NO AUTO PUMP SHUT OFF ®11. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST) '$IDI FLOW SHUT 11. AUTOMATIC LEAK DETECTOR OFF OR RESTRICTION ❑12. ANNUAL INTEGRITY TEST(0.1 GPH) ❑12. ANNUAL INTEGRITY TEST(0.1 GEN) SUCITON/GRAVTIY SYSTEM SUCTION/GRAVITY SYSTEM ❑13. CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS ❑13. CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS EMERGENCY GENERATORS ONLY(Check all thrt.Wy) EMERGENCY GENERATORS ONLY(C k 41 e t apply) 16 14. CONTINUOUS SUMP SENSOR y7gjQ{I1 AUTO PUMP SHUT OFF• [314. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFT AUDIBLE AND VISUAL ALARMS AUDIBLE AND VISUAL ALARMS ❑15. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)WffHOUT FLOW ❑15. 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 GPH) ❑17. DAILY VISUAL CHECK ❑17. DAILY VISUAL CHECK VII.DISPENSER CONTAINMENT DISPENSER CONTAINMENT ❑1.FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE ❑4.DAILY VISUAL CHECK DATE INSTALLED 4641 ❑2.CONTINUOUS DISPENSER PAN SENSOR+AUDIBLE AND VISUAL ALARMS ❑S.TRENCH LINER/MONITORING (33. OUS DISPENSER PAN SENSOR MM AUTO SHUT OFF FOR ❑6.NONE 469 DISP SER+AUDIBLE AND VISUAL ALARMS DL OWNER/OPERATOR SIGNATURE I cu6y the the and wt bemafmyk,mwlefr. . SIGNA F O DATE / 476 NAMEOFOWNER/ OR(pmt) 471 TITLE OF OWNER/OPERATOR 4n So N F G permit Numbs(Fs l.dumedy) 473. Pmmil Appovd(Foc lout use ONy) 474 Potosi pap'union D+te(For loW ux only) 475