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UNIFIED PROGRAM CONSOLIDATED FORM TANKS 'UNDERGROUND STORAGE TANKS-TANK PAGE 2 VI.PIPING CONSTRUCrION Chstk all lltat UNDERGROUND PIPING ABOVECrROUND PIPING SYSTEM TYPE 1.PRESSURE. ❑2.SUCTION ®3.GRAVITY 458. ❑1.PRESSURE [12.SUCTION ❑3.GRAVITY 459. CONSTRUCTION/ ❑1.SINGLE WALL ❑3.L..NED TRENCH ❑99.OTHER 460. ❑1.SINGLE WALL ❑95.UNKNOWN 462. MANUFACTURER 19 2 DOUBLE WALL ❑95.UNKNOWN ❑2.DOTJALE WALL ❑99.OTLLER MANUFACTURER Q r 5� 461- MANUFACTURER 463. ❑1.HARE STEEL ❑6.IRP COMPATIBLE W/100%METHANOL ❑1.HARE STEEL 1]6.FRP COMPATIBLE W/1 00%- ❑2.STAINLESS STEFL ❑7.GALVANIZED STEEL CI 2.STAINLESS STEEL ❑7.GALVANIZED STEEL V ASTIC COMPATIBLE..WITH CONTENTS ❑95.UNKNOWN ❑3.PLASTIC.COMPATIBLE W/CONTENTS D 8.FLEXIBLE(HDPE) 99.OTHER IBERCH ASS ❑8.FLEXIBLE(HDPE) ❑99.OTHER ❑4.FIBERGLASS ❑9.CATHODIC PROTECTION ❑5.STEEL W/COATING ❑9.CATHODIC PROTECTION a64. ❑5.STEEL.W/COATING ❑95.UNKNOWN 465. V IL PIPING LEAK DETECTION(Check all that v)(A dt eription o(tke ttxmdai mall B aV Lfj cd to NT PI a y. iINDERGROJJND PIPING AAOVEGROUND PIPING I SINGLE WALL.PIPING 46& SINGLE WALL.PIPING 461' PR URI7.F,D PIPING(Check all chat apply) PRESSURIZED PIPING(Check atl that apply)-. 1. ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TFST WITH AUTO PUMP ❑1. ELECTRONIC LINE LEAK DETECTOR"t.0 GPH TEST WITH AUTO PUMP SHAT-OFF FOR ITAK,SYSTEM FAUVRF,AND SYSTF,M DISCONNECTION +MUDOIs F FOR I,FAK,AND VISUAL TEMALAFAILURE,AND SYSTFM DISCONNECTION +AUDIBLE AND VISUAL ALARMS. ❑2. MONTHLY 0.2 GPH TEST []2. MONTHLY 0.2 GPH TEST ❑3. ANM)Ai,rNTEoR1TY TE5T(0.1 CPR) [33. ANMJA1.INTEGRITY TEST(0.1 GPH) 04. DAILY VISUAL CHECK CONVENTIONAL.SUCTION SYSTEMS CONVENTIONAL SUCTION SYSTEMS(Check nil that apply) ❑5. DAILY VISUAL MONITORING OF PUMPING SYSTEM+TRIENNIAL PIPING [35. DAH-Y VISUAL MONITORING OF PIPING AND PTJMPTNG SYSTEM INTEGRITY TEST(O.l GFH) SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): [3 6. TRIENNIAL INTEGRITY TEST(0.1 GPH) 0'7. SELF MONITORING SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): GRAVITY FLOW ❑7. SELF MONITORING []9. BIENNIAL INTEGRITY TEST(0.1 GPH) C:RAVITY FI.O`V(Check all that apply): [18, DAILY VISUAL MONITORING [39. BIENNIAL INTEGRITY TEST(0.1 GPH) SECONDARILY CONTAINED PIPING SECONDARILY CONTAINED PIPING PRESSURTLED PIPING(Check all that apply): PRESSURIZED PIPING(Check all that apply): to. C'ONTLNTJOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL. 10. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL i AT.ARMS AND(Check one) ATARMS AND(Check ora) �a.AUTO PUMP SHUT OFF WHEN A LEAK OCCURS O a.AUTO PUMP SIIUT OFF WHEN A LEAK OCCURS i,.AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM ❑b.AUTO PUMP SHUT OFT FOR LEAKS,SYSTEM FAILURE AND SYSTEM DISCONNECTION DISCONNECTION ❑c. NO AUTO PUMP Stn)T OFF ❑c. NO AtJTO PUMP SHUT OFF 1 1. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)WITH FLOW SHUT ❑1).AUTOMATIC J.EAK DETF(:TOR ` OFF OR RESTRICTION ❑12. ANNUAL INTEGRITY PEST(0.1 OPH) bRl ICK0-Ajq ❑12.ANNUAL INTEGRITY TEST(0.1 GPH) SUCTION/GRAVITY SYSTEM SUCTION/GRAVTTY SYSTEM E313. CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS ❑11.CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL,ALARMS EMERGENCY GENERATORS ONLY(Check a1)char apply) EMF,Rt.,ENCY C:F.NERATORS ONLY(Check n11 that apply) ❑14. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF ❑14. AUDIBLE CON A ANA VISUAL AORMSTL�UUT AUTO PUMP SHUT OFF AUDIBLE AND VISUAL_ALARMS ❑15. AUTOMATIC' LANE LEAK DETECTOR (3.0 GPH TEST) WITHOUT FLAW ❑15.AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST) SHUT OFF OR RESTRICTION ❑16. ANNUAL INTEGRITY TEST(0.1 GPH) ❑16.ANNUAL 1N iliGR1TY TEST(O.l GPH) t [117. DAILY VISTIALCHECK ❑17. DAILY VISUAL CHECK. VIII.DISPENSER CONTAINMENT DISPENSER CONTAINMENT 468. ❑1. FLOAT MECHANISM TLiA,r SHUTS OFF SHEAR VALVE, a, DAILY VISUAL Ci1ECK 469. r_- _ �__ DATE INSTALLED pj, ❑2. CONTINUOUS DISPENSER PAN SENSOR+AUDIBLE AND VISUAL ALARMS ❑5. TRENCHILINER MONITORING ❑3. CONTINUOUS DISPENSER PAN SENSOR MM AUTO SLUT OFF FOR x' NONE DISPENSER+AUDIBLE AND VISI.IALALARMS moi m OWNF.RIOPERATOR SIGNATURE I cert dw inf ation provi herein i5 true an accurate m the hest of my knowledge. 470 TIT1,F OF OWNFR/OPERATOR: l NAME OF TN�J�R/C)PPtRATOORt(P(lot): IJV �"` 1 ��jj ``��''��'�� 473. Permit Approved By(Agency use wt(y) 474. Permit Expiration wa in Date(Agency use only) 475. Permit Number(Rgecicy U%e only) UPCF hwfwre-h(1/99)-3/4 http://www.unidaes.aM Rev.02/10/00