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UNIFIED PROGRAM CONSOLIDATED FORIM TANK. TAvA&37s PRO, PR0231161 F. UNDERGROUND STORAGE TANKS-TANK(PAGE 2 PAC#-. FAOMn6 vi.PIPIlGCONS'rRU('TTi oN(ch koathxappty) Page> r; UNDEROROUND PIPING ABO VEGRULti�PIPIIv(i SYSTF.M'1'XPE I.PRf.$$tJl(g ❑2.S[1CTION ❑3.GRAVITY 459 0 I.PRESSURE ❑2.SU'C.I]ON M 3.CRAVITY 4,9 roNSTRULTIoN ❑I.SINULE WALL 03•LINEDTRENC1i ❑99.OTHER 460 ❑ I.SINGLE.WALL 0 95.UNK.NOIYN 462 Wt DOUBLE WALL ®9;.UNKNOWN ❑2.DOUBLE WALL El99.OTHER MANLiFACTURER 46' MANUFACTURER 463 ❑ I.BAk6 ST'F:Ni. _ ❑6.FkP COMPAT'IHI,h w1 IWX,METHANOL ❑ t.HARE STEEL ❑6.FRP COMPAT':BLE wt I00%MF.THANOL ❑2.STAINI Y.SS STEEL ❑7.C+AI,VANIZED STrrL ❑2.STANE.FSS STEEL ❑ 7.GALvANLZED STEEL CI PLASTICCOMPA7'IHLEW/CONTENTS ❑95XN14NOWN ❑PI.AST'ICCOMPATIMl.F.WICO,\TL•NTS ❑95.lINKN016',N fIHUR(iLASS ❑ S.FLEXIBLE(HDPE) ❑99.0TTIER ®4.rmp.giLA55 ® a,FLEXIBLE(HDPE) [] 99.OTHER 5.S'1'r1;'L W/COATTNG ❑9.CA'!'HOD/C PROTL•CTION 464 171 5.STEEL W/COA'rLNU Q 9.CATHODIC PROTCCTION 465 YIL PIPING I.I;:,eaC DkTEC'I'i0I1([7�.E that apps»IA descrlpelen of the alwlitotina FmP.�I>u YMa be sub¢riae6 io[he kigt ay,�lcy,) ,. UNDF.RGROUNU PIPING ABOVECROUNU PIPING SINGLE WAI.I.PIPING 40 $nK;LE WAI.1.'PIPING 467 PRESSURIZED PIPING(Check.all that Apply): PRF.0.URIZED PIPIOC(Cheek all tilat Apply): ❑ I.):LLECIRUNIC LINE LEAK 17FTECTOR 3.0 OPH TEST WIT]I MITA PUMP SHUT OFF ❑ I.ELECTRONIC LENT TF..AP DE'recrOR 3.0 GPH TESL'Aali.AUTO PIMP SHUT OFF FOR LEAK,SVSr(;M FAILURE,AND SYSTEM DT.SCONNEC1'ION+AUDIBLE AND FOR LEAK,SYSTEM FAILURE.AND SY,.5TF-:M DISCONNECTION+Alf AHLE AND VISUAL ALARMS, VISUAL ALARMS, (7 2.MONTI IL.Y 0.2 GPH TEST ❑2.MONTHLY 0.2 GPI I TEST ❑3.ANNUAL rNTh'(.RrrY TEST(0.1 GPII) ❑3.ANN(;AI.INTEGRITY TEST(0.1 GPIQ ❑4.DAILY VISUAL C1rr..CK CONVENTIONAL SUCTION SYSTEMS CONVENT10NAI:SUCT10N SYSTEMS((..V:ck all that apply) ❑5.DAILY VISIIAI.MO\rPORINU OF PUMPING SYSTEM�TRIEWIEAL. PIPLNU ❑ S.DAILY VISUAL MONITORING OF PIPING AND PUMPIM)SYSTEM INTEGRITY'1' sr(0.1 GPII) ❑(>.'rRIEVNUIL I.�TEGRFFY TFS'r(0.!GPIs) SAFE SUCTION SYSTEMS(NO VALUES IN BELOW CROl1N1)PTPING): SAFE St1(ITION SYDTEMS(NO VALIIP:$IN BELOW GROUNDPIPINC;): ❑7.SELF MONITORING '❑7.SELF MONITORING CRAVITY FLOW ❑9.BIENNIAL INTEGRITY TEST(o.I)GPH GKAvrrY FLOW(Cheek all that apply): ❑S.DAI1,.Y VI$UAL MONrrORIXG 19.BIENNIAL INTEGRITY TEST(o•1)OPH f' SECONDARILY CONTAINED PIN NG SF:COeD,UULYCONTAINED PIPIN(; PRESSURIZED PIP114C(Check all that apply)! PRIMUkIZED PIPINGCheck all h ( that 10.C,:()N'I'IN000$TURBINE SUMP SENSOR$PTII AUDIBLE AND VISUAL In.CONTNLtOUS TURBINE SUMP SK.N%OR WITI l AUDIBLE AND VISUAL ALARMS AND(eked:emeJ ALARMS AN U Khak one) +.' a.AUTO PUMP SMIT OFF WHEN A LEAK 000JR5 �❑t a.AUTO PUMP Sl tUT OFF WHEN A 1 EAE OCCURS 59 b.AUTO PUMP$1ItiT Orr FOR LEAKS,SYSTEM FAIM IRE AND 5Y&TrtM U b,AUTO PU MP SL NUT OFF FOR L.F.AKS,SYSIT.M FAIL:URE AND SYSTEM DISCONNECTION DISCONNECTION ❑c.NO AUTO PUMP SHUT OFF ❑C.NO AUTO PUMP SHUT OFF 11.AUTOMATIC LINE LEAK DUI-ECTOR(3.0 OPti,M$I,)WITH FLOW 1,11UT OFF OR ❑ 11.AUTOMATIC LEAK DETECTOR RESTRICTION 12.ANNUAI.rNTF.GRITY TTLST(0.I GPH) ❑ 12.ANNUAL INTEGRITY TEST(0,1 GPH) SUCTIONIGRAV ITY SY$1'1:M S'UCTTON/GRA-ITY SYSTEM 1-1 13.C ON'TINI11N lA SUMP SENSOR 1 AUDIBLE AND VISUAL ALARMS I l 13,CONTINUOUS SUMP SENSUR+AUDIBLE AND VISUAL ALARMS EMERGENCY GENERATORS ONLY(CIRek all ft apply) C31ERG6:ICY GENERATORS ONLY((:heck all dui 2ppl�) ❑ 14.CONTINUOUS SUMP 5I(N1;OR WITHOUT AUTO PUMP SHUr OFF+ ❑ 14,CONTINUOUS SUMP SENSOR WITI I T AUTO PUMP SHUT OFF° AUDIBLE AND VISUAL ALARMS AUDIBLE AND VISUAL AL.AR.MS o 15.AUTOMATIC LNE LEAK DETECTOR(3.0 GPH TFST)WTTHQU FLOW ❑ 15.AUTOMATIC LINE LEAK DETECTOR(3.0 GFH TEST)WITHOUT FLOW SH(tT OPT OR RESTRICTION SHUT OFF OR RESTRrCTION ❑ 16.ANNUAL INTECiRrrY TFST(o.1 GPH) ❑ 16.ANNUAL INTEGRITY TFST(9,I GPI 1) ❑ 17.DAILY VISUAL CHECK ❑ 11,DAILY VISUAL CHECK VIII.DISPENSER CONTAINMENT D1SPF,NSEKCONTAINMENT ❑ 1.PLOATMECILANISMTITATSHUTS OFF SHEAR VALVE Mt 4.UAILYVISUALCCK PATE INSTALLED ❑ 469 ❑2.CONTINUOUS DISPENSER PAN SENSOR�AUbJ8LE AND VISUAL ALARMS ❑S.TRRNCIi LINER/MONITORNG 3.CONTINUOUS DISPENSER PAN SENSOR WM I AUTO SHUT'OFF FOR ❑6.NONE. DI.SPRNShK+AUDIBLE AND VISUAL ALA - 400 Ix.OWNI:IvcarlcRA r01�sIGNnTaR1: I ceNri ami ax Infmmaekm p�;de�h�ja g uue Walkh:wate l a e twa ,•browkd¢e. S1GNA'L'URE OF OWNER/OPERAT 410 NAMF.OFOWNER/OPERATOR(pliht) '1'rt'LE DFOWNF.R!OP1-:RA'rUR �rY`�. ��iF•.s// �'1 0 /V 472 Phitat Numha(For I"ol use only) 47.1 I'm1h ApproVed(Fa I.-1,mc only) 474 Permit Fxp;ration D.j.(Far focal use orH,) 475 PT0004361 EE0003804 12/-31/2000 1,IPC:F(12/09 revised) Ed WUS57,:OT R00Z 90 -U?f Z8S0-bS6-60z 'ON XUA NONAf AHO S,>IOIN : WONA