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<br /> UNIFIED PROGRAM CCIINSOUDATED FORM TANK, TAQ308377
<br /> PR 9: PRO23116i
<br /> UNDERGROUND STORAGE TANKS'I'ANK PAGE 2 FACO: FAUGQM(,
<br /> AIS
<br /> 0 77
<br /> 6,
<br /> JR
<br /> 00372
<br /> PIPING CONSI'RUCTIC0
<br /> JNDEXC,_R0UNi)pIpiic P.,,c or 7
<br /> AtOVE(;I�O_UNID F11-p-NG
<br /> SYSTL•M'rvPE 1. L�mz 02 wurION El ;.c,,RAvjTy 458 ❑2.SUCTION uRAvrry 459
<br /> CONS-MUCTION Cj 1.SINGLE WALL Eli.LINED TRENCI I CJ P9.0 I-hER I-SINGLE
<br /> WALL, 0 95.UNKNOWN
<br /> 461
<br /> MANDFACTURRK OW z DOU'AI-F WALL 09.,.UNKNOWN 461 U3 2.DOUBLE WALL oTHrm
<br /> MANUFACTURER 463
<br /> ❑ 'L
<br /> 1.13ARPSTE111- ❑6.FRP COMPATIBLE w 100%,\4LI-KAN0L -5 1.ElAli�STEEL 0 CI,FRP COMPATIT11.E w Do%mr.I-KAxoj.
<br /> ❑2.STAINLESS S-MF;L ❑7.GALVANIZED STEEL El 2.STAINLESS STEEL EJ 7.GALVAN17EL)S711,fl.
<br /> C3 PLASTIC COMPATirl LE W/CONTENTS El I)S-UNKNOWN F-1 ll"STICCO.MPAI'IBLrwicoNTF.Ni,s
<br /> 1�4.Fj3r,.R()LASS 0 )s.UNicNOWN
<br /> 13 8,FLEXIBLE(I rDPF.) d 99.armER F1 4.FIBERGLASS F.I-Lr.XldLE((rrvb) C1 09.(FINER
<br /> El-i-SrEm.W/COATnsIG ❑9.CAT11ODIC pp
<br /> ,OTp.CrIf.w 464 L] S.s'rm WICOATING, E3 9.CATHODIC PROTECTION
<br /> 465
<br /> VI I.PIPING 1.,
<br /> IZ!ERGROUNI.)PI PING, BOVRGKOUND PI FIND
<br /> L&WALL PI N(:
<br /> PRPSSURlZF.D FIPINC(CIleek 211 that apply): 4w INGLE WA�IAPAPIN.
<br /> ❑ 1.ELECTRONIC LINE i.PAK D PRkSSURIZED PIPING((.IWL*211 tIML apply):
<br /> DETECTOR 3.0 OPH TEST WITH AUTO Pumi-sj.lUT OFF 0 1.armONIC Lrxx LEAK DRI PUMP,;HLr'rOrF
<br /> FOR LEAK-SYSTEM FAIIAIREL AND SYSTEM 01SCONNrO'11ONr AUDIRLE AND FOR LEAK,SYSTEM FAILURIZ,AND YTFM Dl%CGNNEC7ION+AUDIOLF.AND
<br /> VISUAL ALARMS. VISUAL ALARMS.
<br /> ❑2.MONTHLY 0.2(11-11 TEST
<br /> El 1 ANNUAL INTr(mrry TEST(D.I GPM 0 2.MONTITLY 0.2 GPII TFS-r 3.ANNUAL wmrRl I-Y TFST(0.1 C;P)1)
<br /> 0 4.DAILY VISUAL CHECK
<br /> CONVENTIONAL Strcri ON SYSTEMS CONVENTIONAL SUCTION SYb7EMS(Check ail that apply)
<br /> F-1 S.DAILY VISEIAI.MONITORING oI:KJMPINCiSYSTEM+'I'ME,"NIPAL PIPING 5.DAILY VISIJAI.MONITORING Or PIPING AND JIUMrNG SYSTEM
<br /> INTEGRITY TPS I'(0.1 GP14)
<br /> SAFE.5UCTIO-q SYSTEMS(NO VALI)FS 0 BELOW GjtOUNDP7P ING); ❑6,TRrrNN. IAI.IN=,GkrI-Y'rEST(0.1 UPH)
<br /> 0 7.SM..PMONITORING sAFE sI1<.-rjojN SY91,EMS(NO VALUES IN BELOW CROUINDPI PING):
<br /> GRAVITY FLOW ED 7.SELF MONjT()RIN,(.-
<br /> ❑9.UIENNIA1.INTEGRITY TFS r(0.1)CPH GRAVITY FLOW(Check-all that apply):
<br /> EJ B.DAILY VISUAL MONI-roRrm,
<br /> E] 9.13IT-VNIALINTEGIRrry TEST(o.1)Grit
<br /> SECONDARILY CONTAINED PIPING SECONOARII.Y CONTAINED PIPINC.
<br /> PRERSUEUZED PIPING(Cbmk aft that appty)t PRESSURIZED PIPING(CheCk all that appty)!
<br /> 10.CONT M'OUS TURRNP SUMP SFNSOR.W IOXONTINU
<br /> ALARMS AND(Chwi vac) WITH VISUAL OT!"URBINESUMPSENROP,WITH AUDMI..1i AND VISUAL
<br /> ALARMS AND(Chock oak)
<br /> ❑2.At fTO PUMP S14t JTQFF WI IRN A LEAK(X'CLIK5 Q a-AUTO PLIMP SHUT OFF WHEN A uAK(CCUR$
<br /> At>,AUTO PUMPSICUT OFF FOR LEAK&SYSTEM FAII AIRF,AND SYSTFA4 n b.AUTO PUMP.3M IT c)Fr FOR LEAKS,SYSTFAI FAILURE AND SYSTE-m
<br /> DISCONNECTION DISCONNEX711ON
<br /> ❑c.NO AUTO PUMP SNUT CAT ❑c:.NO AUTO PUMP 314U*r OFF
<br /> vaI I.AUTOMATIC LINE LEAK D1-.rburoR(3.0 QPH TEST)ML2:u FLOW SjruT OFF OR
<br /> RRSTKIC.TION C2 I I AUTOMATIC:LEAK I)FTECTUR
<br /> ymc36
<br /> 12.ANNUAL INTTGKITY TEST(0.1 OPH) 12.ANNUAL RITY'IEST(0.1 GI-H)
<br /> SUCTION/GRAVITY%YSTFjvI SUCTIONIGRAVITYSYSI*EM
<br /> El t-f-CONTIN-t.*()Ll'iJUMP sr:N.jor,+AUDTRI.I.AND VL',ZIALALARMS ❑ 1$,CONTMtOUS SUMP SENSOR�AUDIBLr-,AND VISUAL ALARMS
<br /> EMERGENCY CPNYRATOP-9 ONLY(Chea.n ik,(appM E�IAERC;ENC.'YGLi4ERATOItSONI.Y(r.lwkafltl.ippty)
<br /> 177 14.(.'.(>NTINU(-)US SUMP SENSOR WITHOU I AUTO PUMP SHUT OFF 14.CONTINUOUS SITNIFSENSOR Ag
<br /> AUDIBLE AND VISUAL ALARMS AUDIBLE AND VISUAL ALARMS jF1,01M AUTO PUMP SHUT OFF 4
<br /> ED 15,AUTOMATICLIN T.I-IAKDETFC1OR(3.0OPHTEST)WITW,)I-I,r FLOW 0 15.AUTOMATIC LINE LEAK VETECTOR(3.0 GPH TEST)WITHOUTFLOW
<br /> HUT OFF OR RESTRI('TION SHUT OR RFSTP rmm❑
<br /> Ia.ANNIIAI.INTEGRITY TEJl'(O.I(;PI4) ❑ 16.ANNUAL INTEGRITY TAT(0.1 01-ti)
<br /> 17.DAILY VlSUALcmrCK 17.DAILY VISUAL Cl MCK
<br /> DISPENSER CON'rAINMEN1, V 1(1,DISPYNSER CONTAIN MENT
<br /> DATr INSTALLRD 46R C1 I.FLOAT MECHANISM THAT SPRITS OFF SI VALVE (3 4.DAILY VISLIAL CHECK
<br /> 0 1 CONTINUOUS DISPENSER PAN SENSOk+AUDIRI.6 AND VISUAL ALARMS 2 S.TRF.NCIlLrATF.R/,MO*,N'[T()RrNC,
<br /> 5K1 CONTTNIJOUS DISPENSER PAN SENSOR WITH AUTO SHUT OP):FOR 0 6-NONE
<br /> DtSPENSFR+AUDIRIX AND VISUAL ALARMS
<br /> 469
<br /> 5 V,WNATLiRj
<br /> 'kArdxdNR7S- -
<br /> KWOPE
<br /> kI cam;ry'hit the Inn611,161m pm id,,j hemill i. tc at uric to dre ba my W,Lrwlcd,Rc.
<br /> IGNATI IRF Or OW
<br /> DATE
<br /> 470
<br /> NAME or OW,NE.R/QJ1t;RANK
<br /> ''IT
<br /> 11TI-F OF OWXhIVOPFRATOR
<br /> Fnn.' aan'taw lFrs fociOu-mly) 473 Premia nlN,r�rd(Fw T-1
<br /> PT6f 00043EF0003804 whirl 474PerrnEXP11-1 ion LIal.I For Iowe 4i i
<br /> UPCF(12/99 revised) 12/31/2000
<br /> Vd WIJ62:0T 2002 90 *uef ZGSO-VSG-60E : 'ON XUA N06OBHO S,AOI6 W06A
<br />
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