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UNIFIED PROGRAM CONSOLIDATED FORM . TANKS UNDERGROUND STORAGE TANKS - TANK PAGE 2 VI.PIPING CONSTRUCTION(Check a;/Vta.apply) UNDERGROUND PIPING _ SYSTEM TYPE W�q ABOVEGROUND PIPIPlG ❑ 1. PRESSURE [Lq 2. SUCTION ❑ 3. GRAVITY ❑ 1. PRESSURc' CONSTRUCTIOW ❑ 1. SINGLE WALL ❑ 3. LINED TRENCH ❑99 OTHER ❑ 1. SINGLE WALL ❑ 2' SUCTION ❑ 3. GRAVITY MANUFACTURER 2. DOUBLE WALL ❑95. UNKNOWN ❑95. UNKNOWN MANUFACTURER STlli th FihPrvl^ec pY.�,a ❑ 2• DOUBLE WALL ❑99. OTHER o-�---�• Inc. MANUFACTURER ❑ 1.BARE STEEL ❑ S. FRP COMPATIBLE W/100%METHANOL ❑ 1. BARES TEEL MATERIALS AND ❑ 2, STAINLESS STEEL ❑ 7.GALVANIZED STEEL ❑6. FRP COMPATIBLE W/100%METHANOL CORROSION ❑ 2. STAINLESS STEEL ❑ 7.GALVANIZED STEEL PROTECTION ❑ 3.PLASTIC COMPATIBLE WITH CONTENTS 1195. UNKNOWN ❑ 3. PLASTIC COMPATIBLE WITH CONTENTS _ ❑ B. FLEXIBLE(HDPE) ❑99. OTHER ( 4, FIBERGLASS ❑ 8. FLEXIBLE(HDPE) 1199. OTHER ❑ 4. FIBERGLASS ❑ S. STEEL W/COATING ❑ 9CATHODIC PROTECTION ❑ B• CATHODIC PROTECTION ❑ 5. STEEL W/COATING ❑95. UNKNOWN ' VII.PIPING LEAK DETECTION(Check all that appy) UNDERGRO�NIN - 1 flE WALL,PIPING ABOVEGROUNO PIPING URIZ=-O PIPING(Check all Ina(apply): PRESSURIZED PIPING Cheek a!I that appy):ELECTRONIC UNE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP SHUT OFF FOR ( PPM LEAK,SYSTEM FAILURE,AND SYSTEM DISCONNECTION• ❑ 1• ELECTRONIC UNE LEAK DETECTOR 3.0 GPM TEST WITH AUTO PUMP SMUT OFF FOR LEAK, ALARMS AUDIBLE AND VISUAL SYSTEM FAILURE,AND SYSTEM DISCONNECTION+AUDIBLE AND VISUAL ALARMS ❑ 2. MONTHLY 0.2 GPM TEST ❑ 2. MONTHLY 0 2 GPM TEST ❑ 3.ANNUAL INTEGRITY TEST(0 1 GPH) ❑ 3. ANNUAL INTEGRITY TEST(0.1 GPM) ❑ 4, DAILY VISUAL CHECK CONVENTIONAL SUCTION SYSTEMS. CONVENTIONAL SUCTION SYSTEMS(Check all that apply): ❑ S DAILY VISUAL MONITORING OF PUMPING SYSTEM+TRIENNIAL PIPING INTEGRITY ❑ 5. DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM TEST(0 t GPM) ❑ 6. TRIENNIAL INTEGRITY TEST(0.1 GPM) SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): ❑ 7. SELF MONITORING SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): GRAVITY FLOW ❑ 7• SELFMONITORING ❑ 9. BIENNIAL INTEGRITY TEST(0 1 GPM) GRAVITY FLOW(Check a7 that apply): ❑ 8. DAILY VISUAL MONITORING SECONDARILY CONTAINED PIPING ❑ 9. BIENNIAL INTEGRITY TEST(0.1 GPM) PRESSURIZED PIPING(Check all that appy) SECONDARILY CONTAINED PIPING 10. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL ALARMS AND PRESSURIZED PIPING(Check am that appy): (Cretk one) 11 a AUTO PUMP SHUT OFF WHEN A LEAK OCCURS WITH 10.CONTINUOUS TURBINE SUMP SENSOR AUDIBLE AND VISUAL ALARMS AND(Check one( ❑ 0 AUTO PUMP SHUT OFF FOR LEAKS.SYSTEM FAILURE AND SYSTEM 11a. AUTO PUMP SHUT OFF WHEN A LEAK OCCURS O-SCONNECTION ❑ b. AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM DISCONNECTION ❑ c NO AUTO PUMP SHUT OFF ❑ C. NO AUTO PUMP SHUT OFF ❑ 11. AUTOMATIC LINE LEAK DETECTOR(3.0 GPM TEST)WITH FLOW SHUT OFF OR RESTRICTION ❑ it. AUTOMATIC LEAK DETECTOR Cl 12 ANNUAL INTEGRITY TEST(0 1 GPM) ❑ 12. ANNUAL INTEGRITY TEST(0.1 GPM) SUCTION/GRAVITY SYSTEM: 13 CONTINUOUS SUMP SENSOR•AUDIBLE AND VISUAL ALARMS SUCTION/GRAVITY SYSTEM: ❑ 13. CONTINUOUS SUMP SENSOR-AUDIBLE AND VISUAL ALARMS EMERGENCY GENERATORS ONLY(Check all that apply) 14, CONTINUOUS SUM?SENSOR WITHOl1T AUTO PUMP SHUT OFF+AUDIBLE AND EMERGENCY GENERATORS ONLY(Check alJ that apply) VISUAL ALARMS „ ❑ 14. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF•AUDIBLE AND VISUAL ❑ IS. AUTOMATIC LINE LEAK DETECTOR(3.0 GPM TEST)WITHOUT FLOW SHUT OFF OR ALARMS RESTRICTON ❑ 1S. AUTOMATIC LINE LEAK DETECTOR(3.0 GPM TEST) ❑ 16.ANNUAL INTEGRITY TEST(01 GPM) ❑ 16.ANNUAL INTEGRITY TEST(0.1 GPM) ❑ 17, DAILY VISUAL CHECK • ❑ 17. DAILY VISUAL CHECK VIIL DISPENSER CONTAINMENT DISPENSER CONTAINMENT ❑ 1 FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE DATE INSTALLED ❑ 2.CONTINUOUS DISPENSER PAN SENSOR+AUDIBLE AND VISUAL ALARMS ❑ 4. DAILY VISUAL CHECK 133. CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR DISPENSER+AUDIBLE AND VISUAL ALARMS R8.NONE TRENCH LINER)MONITORING I canny that Ine In/onnahon p ide0 na ein is we and a IX.OWMERlOPERATOR SIGNATURE Lata t Ina bast of my knowledge. SIGNATUP.EOFOWN PERATOR DATE 1 NAME OF ""ER R 7I1/L.❑❑Z (pant) TITLE OF OWNER OPERATOR G e B r Permit Num:ar/Forloca!use an !Y) Permit Approved(For local use only) Permit Expiration Date(For local u3a only) :UPAFORM(4/99)