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„r �r x , NIFIED PROGRAM CONSOLIDATED �M N TANKS UNDERGROUND STORAGE TANKS - TANK PAGE 2 VI.PIPING CONSTRUCTION(CAeck aha that apply) UNDERGROUND PIPING ABOVEGROUND PIPING SYSTEM TYPE t PRESSURE ❑ 2. SUCTION ❑ 1. GRAVITY ❑ 1. PRESSURE ❑ z. sucnoN ❑ i. caavlry CONSTRUCTION/ ❑ 1. SINGLE WALL ❑ 3. LINED TRENCH ❑99. OTHER ❑ 1. SINGLE WALL ❑95. UNKNOWN MANUFACTURER ® 2. DOUBLE WALL ❑95. UNKNOWN ❑ 2. DOUBLE WALL MANUFACTURER SM T TN _ R F s TREAD El 99. OTHER MANUFACTURER ❑ 1.BARE STEEL ❑ 8. FRP COMPATIBLE WI 100%METHANOL ❑ I. BARE STEEL ❑ 8. FRP COMPATIBLE Wl 100%METHANOL MATERIALS AND ❑ 2. STAINLESS STEEL ❑ 7. GALVANIZED STEEL CORROSION C12. STAINLESS STEEL C17. GALVANIZED STEEL PROTECTION ❑ 3. PLASTIC COMPATIBLE WITH CONTENTS ❑95. UNKNOWN ❑ 3. PLASTIC COMPATIBLE WITH CONTENTS ❑ 8. FLEXIBLE(HDPE) ❑99. OTHER ICI 4. FIBERGLASS ❑ 8. FLEXIBLE(MOPE) ❑99. OTHER ❑ 4. FIBERGLASS ❑ 9. CATHODIC PROTECTION ❑ 5. STEEL W/COATING ❑ 9. CATHOOIC PROTECTION ❑ 5. STEEL W/COATING ❑95. UNKNOWN VII.PIPING LEAK DETECTION(Check aI that apply) UNDERGROUND PIPING SINGLE WALL PIPING ABOVEGROUND PIPING PRESSURIZED PIPING(Check all that appy): SINGLE WALL PIPING PRESSURIZED PIPING(Chack as that appy); ❑ I. ELECTRONIC LINE LEAK DETECTOR 7.0 GPM TEST WITH AUTO PUMP SHUT OFF FOR ❑ 1. ELECTRONIC LINE LEAK DETECTOR 3.0 GPM TEST WITH AUTO PUMP$HUT OFF FOR LEA ALARMS . K, LEAK.SYSTEM FAILURE,AND SYSTEM DISCONNECTION.AUDIBLE AND VISUAL SYSTEM FAILURE.AND SYSTEM DISCONNECTION AUDIBLE AND VISUAL ALARMS ❑ 2. MONTHLY 0.2 GPM TEST ❑ 2. MONTHLY 0.2 GPM TEST C3 1. ANNUAL INTEGRITY TEST(0.1 GPM) C13. ANNUAL INTEGRITY TEST(0.1 DPH) I ❑ 4. DAILY VISUAL CHECK - CONVENTIONAL SUCTION SYSTEMS: CONVENTIONAL SUCTION SYSTEMS(Check ad that appW: i ❑ 5. DAILY VISUAL MONITORING OF PUMPING SYSTEM•TRIENNIAL PIPING INTEGRITY ❑ 5. DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM TEST(0.1 GPM) ❑ 8. TRIENNIAL INTEGRITY TEST(0 1 GPM) SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): ❑ 1. SELF MONITORING j ❑ 7. SELF MONITORING GRAVITY FLOW GRAVITY FLOW(Check at that appy): ❑ 9. BIENNIAL INTEGRITY TEST(0.1 GPM) ❑ d. DAILY VISUAL MONITORING ❑ 9 BIENNIAL INTEGRITY TEST(D.t GPM) SECONDARILY CONTAINED PIPING PRESSURIZED PIPING(Check ail that appy): SECONDARILY CONTAINED PIPING PRESSURIZED PIPING(Check aI that appy): 10. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL ALARMS AND 1(Choa one) 10.CONTINUOUS TURBINE SUMP SENSOR NTH AUDIBLE AND VISUAL ALARMS AND(check one) ' a. AUTO PUMP SHUT OFF WHEN A LEAK OCCURS ❑ a. AUTO PUMP SHUT OFF WHEN A LEAK OCCURS ❑ b. AUTO PUMP DISCONNECTIONT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM ❑ D. AUTO PUMP SHUT OFF FOR LEAKS.SYSTEM FAILURE AND SYSTEM DISCONNECTION �t�yy ❑ c NO AUTO PUMP SHUT OFF ❑ c NO AUTO PUMP SHUT OFF yL It AUTOMATIC L NE LEAK DETECTOR(3.0 GPM TEST)NTH FLOW SHUT OFF ORREST ❑ 11. AUTOMATIC LEAK DETECTOR ❑ 12. ANNUAL INTEGRITY TEST(0.1 GPM) ❑ 12. ANNUAL INTEGRITY TEST(0.1 GPM) SUCTtOWGRAVITY SYSTEM: SUCTION/GRAVITY SYSTEM: ❑ 13. CONTINUOUS SUMP SENSOR•AUDIBLE AND VISUAL ALARMS ❑ 13. CONTINUOUS SUMP SENSOR•AUDIBLE AND VISUAL ALARMS EMERGENCY GENERATORS ONLY(Check aI that appy) EMERGENCY GENERATORS ONLY(Check N that appty) ❑ 14. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF.AUDIBLE AND ❑ 14. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF.AUDIBLE AND VISUAL VISUAL ALARMS ALARMS ❑ 15. AUTOMATIC UNE LEAK DETECTOR(3.0 GPM TESTI VIATHOUT FLOW SHUT OFF OR ❑ 15. AUTOMATIC UNE LEAK DETECTOR(3.0 GPM TEST) RESTRICTION ❑ 18. ANNUAL INTEGRITY TEST(0.1 GPM) ❑ 18. ANNUAL INTEGRITY TEST(0.1 GPM) ❑ 17 DAILY VISUAL CHECK Cl 17. DAILY VISUAL CHECK VIII.DISPENSER CONTAINMENT DISPENSER CONTAINMENT ❑ 1. FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE ❑ 4. DAILY VISUAL CHECK DATE INSTALLED ❑ 2. CONTINUOUS DISPENSER PAN SENSOR-AUDIBLE AND VISUAL ALARMSi ❑ S. TRENCH LINER/MONITORING ' n 9 IR 3. CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR DISPENSER•AUDIBLE AND VISUAL ALARMS ❑ 8. NONE IX.OWNER/OPERATOR SIGNATURE I cerby that the hnfdnnabon provided hereMh is we and accLeale to the best of my knowledge_ SIGNATURE OF OWNER/OPERATOR DATE NAME OF OWNERIOPERATOR(pnn0 TITLE OF OWNER/OPERATOR Perms Number(For local use only) Permit Approved(For local use onty) Perms E iwation Data(For local use only) CUPAFORM(4/99) Formerty SWRC8 Form B