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s IFIED PROGRAM COINSOLIIlATED FO[t14Y TASK: 1'A0SO8376 PR V: PRO231161 UNDERGROUND STORAGE TANKS - TAINK PAGE 2 xAC*-. FAM03726 VI.PIPING CONSTRUCTION(c,k,Il that appy) P.v ti ot'l i1Nf)tRCiROCTNt7 P[I'fNG ABOVF.GKUUAiJ PIF'(N(j SYSTEM TYPE I.PRESSt1HF. �]'L.SUC 1'ION Cl 3.URAVITY big ElI.PRVSSURE ❑ 2.SUCTION Q ;.GRAVITY *9 C.ONSPRU TION ❑1.SMOI.F.WALL 03.LINED TRF.NCH ❑99.OTHER 400 [] 1.SArGt.E WALI. ❑0'S.UNKNOWN 46x a DOUBLE WALI. ❑95.11NKNOWN ❑ MANUFACTt1RfR ro ❑2.!)UUBLE WAI.t. o0.OT1TER t MANLTACTURER •H,) L7 1.PAM STEEL [1 G.PRN COMPATIBI.F-/loo%METHANOL Q 1.RARE STLFt. Q 0.FRP C.0 VIPATIBLF.w/lW1.METHANOL D 2.STAINl.Rss STL•Et. ❑7.GALVANIZED STEEL. ❑2.STAINLESS STFF.1, ❑7.GALVANIZED STEEL Q PLASTR7C.OMPA'fIBLL•W/(.ON'('ENTS ❑95.11NKNOWN ❑PLASTIC COMPATIBLE W/CONTENTS ❑ q;•UNKNOWN %4•PISERGLA.S.S Q X.FLE?(1Bt.0(HDPB) ❑ 99.OTITF.R ❑a.PISERGI.ASS ❑ S.FrmtSLE(HDPr) ❑'Y).OTHER ❑S.S'rGEL W/COATING Q 9.CATHODIC PROTE.C1'ION 4M []5.STPK W/COATING ❑9.('A'I'HODIC PROTb'CTI0\ Ons VII.PIPING LEAK DETECTION(C.%wk alt that 4V]Y)(A dine 1ption orlhc 22±1orint;proXrn,A.11 be submntel u,ikr 1o(al aRsney.y UNDERGROUND PIPING ABOVROKUUND PIPING ST>dC.LE WALIPIG .. 40 SINC I.F.WALL PIPING PRFSSUIUZE:D PIPING(Chock nil that apptyp PRMURIZFD PIPING(Check all that apple): [] I.ELECTRONIC LINE L&AK rwrwroiz 3.0 OPH TESL'W ITTI ATITO FUMP SiI(1T OF'F Q t.F.1;ECTRONIC LIN'LEAK DF.TP.0 TOR 3.0 GPI4'rIiSf 3MITT1 At.;IY)PUMP S1 rUT OFF FOR I.RAK,SYSTEM FAII.I:RY,.,AND SYSTEM ),SCONNECTION+AUDIBLE AND FOR 1,EAK.SYSTEM FAILURE.AN()SYSTEM DISCONNECTION+AUDIBLE AND VISUAL ALARMS. VISUAL ALARMS. 2.MONTI{I,Y 0.2 GPH TFCT ❑2.MONTIILY 02 0FK TEST 3.ANNUAL INTEGRITY%S'r(0.1 GPII) ❑ I.ANNUAL INTEGRITY TEST(0.1 GPH) Q 4.DAILY VISUAL;CHECK CONVENTIONAL.SUCTION SYSTFMS CONV KNI'IUNAL SUCTION SYSTEMS(Chuck all that apply) ❑S.DAILY VISUAL M(7N1'I'ORING OF Pt1MPtNOSYSTEM+•rRlENNIEAL PII11Nq ❑ 5.DAILY ViSI.IAI:MONITORINU OF PIPIN(,ANO PUMPING SYSTEM INTEURITY TEST(0.l UPI 1) [ [6.TRIFUNtAL lNTf3GR1TY'I'f ST(0.1 GFH) SAFE;SUCTION ITORING (NO VALUES IN BELOW rROU(`DYIPI�(G): Q 7.SF.1.P MONITORING SAFK SUCTION SYSTEMS(.NO VAL.LIES IN BELOW CHOUNDPIPINC): GRAVITY MOW [] 7.SELF MONITORING Q 9.BIPNNIAL iNTEGRITY'1'P:S'I'(0.1)GPII GRAVITY FLOW(Check 211 that appte): Q S.DAILY VISUAL MONITORING Q 9.BIENNIAL INTEGRITY'I'EST(0.1)rPH SECONDANI I.Y CONTAINED PIPMG SECONDARILY CONTALNED PIPING PR I`F,U)UZE:D PIPING(Check all that apply). PRE-Mu UZED PIPING(Cheek all that apply): 10.CONTINUO(1S TUKBINE SUMP SENSOR W -AUDIBLE AN VISUAL 10.CONT[NUOUS'rC1RBINE SUMP SENSOR WITH AUINULE AND VISUAL Ai;ARMSAND(C ckone) AT-ARMS AND(Chxekam) Q a.AU'PU PUMP SHUT OFF W H eNN A LEAK OCCURS ❑a.AU'I'U PUMP Sl JUT OFF WHEN A LEAK()CC'URS ab.AUTO PUMP SHUT OFF FOR 1".SAKS.SYSTEM FAILURE AND SYSTEM Q b.AT1TO PUMP SHUT OFF Folk LEAKS.SYS"Pt M FAILURE AND SYSTEM DISCONNEC'T'ION DISCONNS.C.TION Do,NO AUTO PUMP SHUT'OFF ❑C.NO AUTO PUMP S14UT OFF (� I1.AUTOMA'T'IC LINE LEAK DL•TFC'rOK(.3.0 GPII TEST)W JTH PLOW SPLIT OFF OR ❑ 1 L,AUTOMATIC t.P'AK DETECTOR mXyrIUC'TION 12.ANNUAL INTEC.RrrY TEST(0.I OPI f) ❑ 12.ANNi•1AL IN9'EORITY TEST(0.1 01,11) SLIM. ON/GKAVFTY SYSTF.14 SUC-11UN/C,RAVITY SYtiTEM [l 13.CONTINt10US SUMP SENSOR+AUDIBLE AND VISUAL.AI:AKMS Q 13.CONTINUOUS SUMP SENSOR F AUDIBLE AND VISUAL ALARMS EMP:ROENCY GENERATORS ONLY(Check.11 ta.L.My) EM F.RGP.NCY GENERATORS ONLY(0--k Al that apply) ❑ 14.CONTLNUUUS SUMP SEINSOR W rTI TOUT AUTO PUMP 51111T OFF• ❑ 14.CONTINUOUS SUMP SENSOR KITI IOUT AU 10 PUMP SIR1T OFF AUUISLEAND VISIIAt;ALARMS AUDIBLE AND VISUAL ALARM,(; ❑ 15.AUTOMATIC I.1 Nb LEAK DETECTOR(3 A GPH TEST)W,,II ({_OtIT F1;OW ❑ 15,AUTOMATIC LINE LEAK DF.TF.CI'OR(3.0 GPII TEST)wrrHOUT FIAW SHUT OFF OR RFSTIU(CION SHUT OFF OR RESTRICTION ❑ Id.ANNUAL INTEGRITY TEST(%j GPH) C] 16.ANNUAL INTEGRITY TEST(0.1 GPII) Ll 17.DAILY VISUAI;CHECK Q 17,DAILY VI.S(1A1,CHECK Vill.DISPENSER CON' X.NMENT DISPENSER CONTAINMFN'1' Q I.FLOAT MECI IA14MM THAT SHUTS OFF StIFAR VALVE 4.DAILY VISUAL CHECK UA'I'E iNSFAI.[.F,D I� ❑2.CONTINUOUS DISPFNSF t PAN SENSOR.ALIDIRLE AND VTSI.IAL ALARMS Q 5,TRENCH 1.LNI;R MONITORING 3.CONTINUOUS DISPENSER PAN SENSOR WjIf At1T0 SHUT OFF FOR Q 4.NONE DISPENSER*AUDIBLE AND VISUAL ALARMS 460 IX.OWNF.WOXEIiATOR SIGNATURE 1 certify that LLA` prc ided herein u wue un . rata to the Fest of my tawwtcdye. . . SIGNATURE UFOWNL DATFP.. ... 470 NAME OFOWNF.RlUPbi TOR(Print) TITLE OF OWN F.R/OPL•.'.RA'I'UR �� N^��xl •t rt iL7f'YL� 472 P,xmn,Vpmtrcr(Far katal,ere nuyl R7) Pe.m,t AnD,rcml lFar kx+t Luc only) 47., Parini,tNPa'AQ,,Dam 1Fnr IrK•.il n.c only) 47S FF0004361 EF.0003804 12/31/2000 UPCF(12/99 revised) Zd WIJ82:0T 5700Z 90 'U?f Z8S0-bS6-60Z : 'ON Xdd NONn3HO S(AOIN WOdJ