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RIED PROGRAM CONSOLIDATED FORAW TANKS UNDERGROUND STORAGE TANKS-TANK PAGE 2 Page_-2-. of VL PIPING CONSTRUCTION t:hcckall thatapply) UNDERGROUND PIPING ABOVEGROUND PIPING SYSTEM TYPE fA 1.PRESSURE [12.SUCTION ❑3.GRAVITY 458. ❑1.PRESSURE ❑2.SUCTION ❑3.GRAVITY 459. CONSTRUCTION/ [11.SINGLE WALL ❑3.LINED TRENCH ❑99.OTHER 460. ❑1.SINGLE WALL ❑95.UNKNOWN 462. MANUFACTURER W2.DOUBLE WALL ❑95.UNKNOWN ❑2.DOUBLE WALL ❑99.OTHER MANUFACTURER Ayyoro n 461. MANUFACTURER 463. ❑1.BARE STEEL ❑6.FRP COMPATIBLE W/100%METHANOL ❑I.BARE STEEL ❑6.FRP COMPATIBLE W/1001/6 METHANOL ❑2.STAINLESS STEEL ❑7.GALVANIZED STEEL ❑2.STAINLESS STEEL ❑7.GALVANIZED STEEL ❑3.PLASTIC COMPATIBLE WITH CONTENTS [195.UNKNOWN [13.PLASTIC COMPATIBLE W/CONTENTS ❑8.FLEXIBLE(HDPE) ❑99.OTHER ,%4.FIBERGLASS [18.FLEXIBLE(HDPE) [199.OTHER ❑4.FIBERGLASS ❑9.CATHODIC PROTECTION ❑5.STEEL W/COATING ❑9.CATHODIC PROTECTION 464. ❑5.STEEL W/COATING ❑95.UNKNOWN 465. VIL PIPING LEAK DETECTION(CMck all that ) A iptionofthe tnankoringprogram shall be submitted to the local UNDERGROUND PIPING ABOVEGROUND PIPING SINGLE WALL PIPING 466 SINGLE WALL PIPING 467- PRESSURIZED PIPING(Check all that apply): PRESSURIZED PIPING(Check all that apply): ❑1. ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP ❑1. ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP SHUT-OFF FOR LFAK,SYSTEM FAILURE,AND SYSTEM DISCONNECTION SHUT OFF FOR LEAK,SYSTEM FAILURE,AND SYSTEM DISCONNECTION +AUDIBLE AND VISUAL ALARMS. +AUDIBLE AND VISUAL ALARMS. ❑2. MONTHLY 0.2 GPH TEST ❑2. MONTHLY 0.2 GPH TEST ❑3. ANNUAL INTEGRITY TEST(0.1 GPH) ❑3. ANNUAL INTEGRITY TEST(0.1 GPH) ❑4. DAILY VISUAL CHECK CONVENTIONAL SUCTION SYSTEMS CONVENTIONAL SUCTION SYSTEMS(Check all that apply) ❑5. DAILY VISUAL MONITORING OF PUMPING SYSTEM+TRIENNIAL PIPING E]5. DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM INTEGRITY TEST(0.1 GPH) SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): ❑6. TRIENNIAL INTEGRITY TEST(0.1 GPH) ❑7. SELF MONITORING SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): GRAVITY FLOW ❑7. SELF MONITORING [19. BIENNIAL INTEGRITY TEST(0.1 GPH) GRAVITY FLOW(Check all that apply): ❑8. DAILY VISUAL MONITORING 1719. BIENNIAL INTEGRITY TEST(0.1 GPH) SECONDARILY CONTAINED PIPING SECONDARILY CONTAINED PIPING PRESSURIZED PIPING(Check all that apply): PRESSURIZED PIPING(Check all that apply): to. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL 10. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL ALARMS AND(Check one) ALARMS AND(Check one) ❑a.AUTO PUMP SHUT OFF WHEN A LEAK OCCURS ❑a.AUTO PUMP SHUT OFF WHEN A LEAK OCCURS 14 b.AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM ❑b.AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM DISCONNECTION DISCONNECTION ❑c. NO AUTO PUMP SHUT OFF ❑c. NO AUTO PUMP SHUT OFF ❑11. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)WITH FLOW SHUT ❑11.AUTOMATIC LEAK DETECTOR %AOFF OR RESTRICTION )N 12. ANNUAL INTEGRITY TEST(0.1 GPH) ❑12.ANNUAL INTEGRITY TEST(0.1 GPH) SUCTION/GRAVITY SYSTEM SUCTION/GRAVITY SYSTEM [113. CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS ❑13.CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS EMERGENCY GENERATORS ONLY(Check all that apply) EMERGENCY GENERATORS ONLY(Check all that apply) ❑14. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF ❑14.CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF AUDIBLE AND VISUAL ALARMS AUDIBLE AND VISUAL ALARMS [115. AUTOMATIC LINE LEAK DETECTOR (3.0 GPH TEST) WITHOUT FLOW ❑15.AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST) SHUT OFF OR RESTRICTION ❑16. ANNUAL INTEGRITY TEST(0.1 GPH) ❑16.ANNUAL INTEGRITY TEST(0.1 GPH) [:117. DAILY VISUAL CHECK ❑17.DAILY VISUAL CHECK VIII.DISPENSER CONTAINMENT DISPENSER CONTAINMENT 468. [11. FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE ❑4. DAILY VISUAL CHECK 469. DATE INSTALLED2. CONTINUOUS DISPENSER PAN SENSOR+AUDIBLE AND VISUAL ALARMS 5. TRENCH/LINER MONITORING rO P05ej0 3. CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR ❑6. NONE W DISPENSER+AUDIBLE AND VISUAL ALARMS IX.OWNER/OPERATOR SIGNATURE 1 certify that the information provided herein is true and accurate to the best of my knowledge. SIGNA WN ER/ PERATOR DATE: 470. NAME fWNERaXERATORO riot:fir TITLE OF Ei�'PE GR� 4 72.e Permit Number(Agency use only) 473. 1 Permit Approved By(Agency use only) 474. 1 Permit Expiration Date(Agency use only) 475. UPCF hwfwre-b(1/99)-3/4 http://www.unidocsorg Rev.02/16/00