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UNIFIED PROGRAM CONSOLIDATED FORM <br /> TANKS <br /> UNDERGROUND STORAGE TANKS-TANK PAGE 2 GS <br /> VL PIPING CONSTRUCITON chxt.0 tbd Pye <br /> UNDERGROUND PIPING ABOVEGROUND PIPING <br /> SYSTEM TYPE ErLPRE&SURE Q 2.SUCTION I3 3,GRAVPIY 458 Q 1.PRESSURE -[T2. SUCTION Q 3.GRAVITY 459 <br /> CONSTRUCTION ❑1.SINGLE WALL Q 3.LINED TRENCH Q 99.OTHER 460 . Q 1.SINGLE WALL O 95.UNKNOWN 467 <br /> MAMJFAMOM Q 2 DOUBLE WALL O 95.UNKNOWN Q 2.DOUBLE WALL (]99.OTHER ' <br /> MANUFACTURER 4, 6); . c ilk 461 MANUFACTURER 461 <br /> Q 1.BARE STEEL Q 6.FRP COMPATIBLE wizw% s�iHANq. ❑).BARE STEEL ❑6.FRP COMPATIBLE Wn00fi M6nuNq, <br /> Q 2.STAINLESS STEEL ❑7.GALVANIZED STEEL. ❑LlalmOwa Q 2. STAINLESS STEEL Q 7.GALVANIZED STEEL <br /> [33.PLASTIC COMPATIBLE W/CONTENTS ❑99. 011ier Q 3. PLASTIC COMPATIBLE W/CONTENTS Q 8.FLE=LE(HDPE) Q 99. OTHER <br /> Er-4.FIBERGLASS Q 8.FLEXIBLE(HDPE) Q 4. FIBERGLASS Q 9.CATHODIC PROTECTION <br /> ❑S.STEEL WAAATTNG [19.CATHODIC PROTECTION 461 Q 5. STEEL W/COATING - Q 95.UNKNOWN 465 <br /> VII.PIPING LEAKDETEC170N Chert a0 that A oTthe monitorbm Form shall be u6mobw cm.bd <br /> UNDERGROUND PIPING ABOVEGROUND PIPING <br /> SINGLE WALL PIPING 466 SINGLE WALL PIPING 4a7 <br /> PRESSURIZED PIPING(Cbark all dw appy): PRESSURIZED PIPING(Chak a0 do appy): <br /> ❑1.ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST 1YI17I AUTO PUMP SHUT Q 1. ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST MM AUTO PUMP <br /> OFF FOR LEAK,SYSTEM FAILURE,AND SYSTEM DISCONNECTION+ SHUT OFF FOR LEAK,SYSTEM FAILURE,AND SYSTEM DISCONNECTION+ <br /> AUDIBLE AND VISUAL ALARMS. AUDIBLE AND VISUAL ALARMS. <br /> Q 2.MONTHLY 0.2 GPH TEST Q 2. MONTHLY 02 GPH TEST <br /> Q 3.ANNUAL INTEGRITY TEST(O.IGPH) [13.ANNUAL INTEGRITY TEST(O.1GPH) <br /> Q 4. DAILY VISUAL CHECK <br /> CONVENTIONAL SUCTION SYSTEMS CONVENTIONAL SUCTION SYSTEMS(Cbuk all tbY appy) <br /> ❑5.DAILY VISUAL MONITORING OF PUMPING SYSTEM+TRIENNIAL PIPING Q S. DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM <br /> INTEGRITY TEST(0.1 GPH) <br /> SAFE SUCTION SYSTEMS(NO VALUES IN BELOW GROUNDPIPING): [16. TRIENNIAL INTEGRITY TEST(0.1 GPH) <br /> Q 7.SELF MONITORING SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): <br /> GRAVITY FLOW Q7.SELF MONITORING <br /> Q 9.BIENNIAL.INTEGRITY TEST(0.1 GFH) _ GRAVITY FLOW(Check all"Wpyy <br /> Q 8. DAILY VISUAL MONITORING <br /> Q 9. BIENNIAL INTEGRITY TEST(0.1 GPH) <br /> SECONDARILY CONTAINED PIPING SECONDARILY CONTAINED PIPING <br /> PRESSURIZED PIPING(Cbvt a0 that apply): - PRESSURIZED PIPING(Check all that appy): <br /> 10. CONTINUOUS TURBINE SUMP SENSOR MM AUDIBLE AND VISUAL 10. CONTINUOUS TURBINE SUMP SENSOR MM AUDIBLE AND VISUAL <br /> ALARMS AND(Chuk ow) ALARMS AND(Chit om) <br /> L AUTO PUMP SHUT OFF WHEN A LEAK OCCURS ET a AUTO PUMP SHUTOFF WHEN A LEAK OCCURS <br /> ®b. AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM IN b AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM <br /> DISCONNECTION DISCONNECTION <br /> I]c. NO AUTO PUMP SHUT OFF Qc NO AUTO PUMP SHUT OFF <br /> 11. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)$tel FLOW SHUT 11. AUTOMATIC LEAK DETECTOR <br /> OFF OR RESTRICTION <br /> Q 12. ANNUAL INTEGRITY TEST(0.1 GPH) Q 12. ANNUAL INTEGRITY TEST(0.1 GPH) <br /> SUCTION/GRAVTTY SYSTEM SUCITOTLGRAVRY SYSTEM <br /> R 13. CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS Q 13. CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS <br /> EMERGENCY GENERATORS ONLY(Cbwk a0 Mn appy) EMERGENCY GENERATORS ONLY(Chock a0 aaa appy) <br /> [114. CONTINUOUS SUMP SENSOR WITH AUTO PIMP SHUT OFF• Q 14. CONTINUOUS SUMP SENSOR WITHOIIT AUTO PUMP SHUT OFF <br /> AUDIBLE AND VISUAL ALARMS AUDIBLE AND VISUAL ALARMS <br /> [115. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TES)WITH (!T FLOW Q 15. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST) <br /> SENT OFF OR RESTRICTION <br /> Q 16.ANNUAL INTEGRITY TEST(0.1 GPH) Q 16.ANNUAL INTEGRITY TEST(0.1 GPH) <br /> Q 17. DAILY VISUAL CHECK r]17. DAILY VISUAL CHECK <br /> VDL DISPENSER CONTAINMENT <br /> DISPENSER CONTAINMENT I.FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE Q 4.DAILY VISUAL CHECK <br /> DATE INSTALLED 461 Q 2.CONTINUOUS DISPENSER PAN SENSOR+AUDIBLE AND VISUAL ALARMS Q S.TRENCH LINER/MONITORING <br /> rl 3.CONTINUOUS DISPENSER PAN SENSOR MM AUTO SHUT OFF FOR Q 6.NONE 469 <br /> -DISPENSER+AUDIBLE AND VISUAL ALARMS <br /> LC.OWNER/OPERATOR SIGNATURE <br /> Icatify char te.' i.aur mte.er atony tmortedp <br /> SIGN F O i DATE +ro <br /> /� ld• �000 <br /> NAME OF OWNER/ TOR(pmt) <br /> +71 TITLE OF OWNER/O TOR 472 <br /> L. i L r - F ��h /I'? 1, o <br /> P. Nambr(Fon I.W aaaoay) 4n Parana AppoM(Fw bol W oaly) 474 Peotu Pspuatba Dm(Fm hal ur only) /n <br />