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a UNIFIED PROGRAM CONSOLIDATED FORM TANKS UNDERGROUND STORAGE TANKS-TANK PAGE 2 M. Pae of VI.PIPING CONSTRVCrION C6«kaliti.t UNDERGROUND PIPING ABOVEGROUND PIPING SYSTEM TYPE 1.PRESSURE. ❑2.SUCTION ❑3.GRAVITY 4% ❑I.PRESSURE ❑2.SUCTION [13.GRAVITY 459. CONSTRUCTION/ ❑I.SINGLE WALL ❑3.I..TNF.D TRENCH ❑99.OTHER 460. ❑I.SINGLE WALL ❑95.UNKNOWN 462_ MANUFACTURER p�r2 DOUBLE WALL ❑95.UNKNOWN ❑2.DOUBLE WALL ❑99.OT HER MANUFACTURER p (Nl t 461. MANUFACTURER 463 ❑.1.BARE STEEL [16.FRP COMPATIBLE W/I(NW METHANOL ❑1.RARE STEEL ❑6.FRP COMPATIBLE W/l0D'Y MF.THANOL 0 2.STAINLESS STEEL ❑7.GAL.VANI7.ED STEEL 0 2.STAINLESS STEEL ❑7.GALVANIZED STFFL. ❑3.PLASTIC COMPATIBLE WITH CONTENTS 1395_UNKNOWN ❑3.PLASTIC COMPATIBLE W/CONTENTS ❑R.FLEX[BLE(HDPE) IL-]99.OTHER ❑4.FIBERGLASS ❑R.FLEXIBLE(HDPE) 0 99.OTHER ❑4.FIBERGLASS ❑9.CATHODIC PROTECTION 0 5.STEEL W/COATING 0 9.CATHODIC PROTECTION ctrl. ❑5.STEEL WICOATING ❑95.UNKNOWN 465. V IL PIPING LEAK DETECTION Ichmk aft that IgO)(A iption of the trKmitoring Migranishall tic snbmiued to the toed a y) l)NDFRGROIJND PIPING ABOVEGROUND PIPING SINGLE WALL PIPING cW SINGLE WALL.PIPING 467 PR URIZED PIPING(Check all ttun apply)- PRESSURI7.ED PIPING(Cheek oil that aapply): F! ELECTRONIC LINE LEAK DETECTOR 3.0 GPH 1'F..ST WITH AUTO PUMP 0). FLECTRONIC LINE LEAK DETECTOR 1.0 GPH TEST WiTH AUTO PUMP SMJT-OFF FOR IFAK,SYSTEM FAIIAJRE,AND SYSTF,M DT.SCONNF.CTiON SM JT+AUDIBFFOR VISUAL TEMALAFAILURE,AND SYSTEM DISCONNFCTION +AUDIBLE AND VISUAL.ALARMS. Q 2. MONTHLY 0.2 GPK TEST [32. MONTHLY 0.2 OPH TEST 03. ANNUAL TNTFCrRITY TEST(0.1 OPH) [33, ANNUAL INTEGRITY TEST(0.1 GPH) 04. DAILY ViSUALCHECK CoNVEiNTIONAL SUCTION SYSTEMS CONVENTIONAL SUCTION SYSTEMS(Check nil that apply) 0 5. DAILY VISUAL MONITORING OF PUMPING SYSTEM+TRIENNIAL PIPING (35. DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM INTEGRITY TEST(0.1 GPH) SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): 1716. TRIENNIAL INTEGRITY TEST(0.I GPH) 07. SELF MONITORING SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PiPING): GRAVITY FLOW 0 7. SELF MONITORING ❑9. BIENNIAL INTEGRITY TEST(0.1 GPH) GRAVITY T'LOW(Check all that oppiy): [18. DAILY VISUAL MONITORING [39. BIENNIAL INTEGRITY TEST(0.1 GPH) SECONDARILY CONTAINED PiPING SECONDARILY CONTAINED PIPING PRESSURIZED PIPING(Check all that apply): PRE'SUR17.ESD PIPING(Check all that apply); 110. CONTINUOUS TTJRBINF SUMP SENSOR WiTH AUDIBLE AND VISUAL 10. CCOATIINURMS A S(TURBINE SUMP SENSOR WiTH AUDiBLE AND VISUAL A(. MS AND(Check one) At ck one) AUTO PUMP SITUT OFF WHEN A LEAK OCCURS ❑u.AUTO PUMP SHIJT OFF WHEN A LEAK OCCURS 0 b.AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM ❑b.AUTO PUMP SHUT 01-T FOR LEAKS,SYSTEM FAILURL•AND SYSTEM DISCONNFC.TiON DISCONNECTiON Qc. NO AUTO PUMP SII(JT OFT ❑c. NO AUTO PUMP SIRIT OFF 54/1 AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)WTT7 FLOW SHUT ®1),AUTOMATIC I,EAK DETECTOR OFF OR RESTRICTION ❑12. ANNUAL INTEGRITY TEST(0.1 OPH) ❑12.ANNUAL INTEGRITY TES"T(0.1 Geis) SUCTION/GRAVITY SYSTEM SUCTiON/GRAVITY SYSTEM 0 13. CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS ❑11.CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL:ALARMS EMERGENCY GENERATORS ONLY(Cheek all that apply) F.MF RV.ENCY GFNF1tATORS ONLY(Check n1)that apply) ❑14. CONTINUOUS SUMP SENSOR WITHIUUT AUTO PUMP SHUT OFF ❑14. CODA LF,O S VISUALstYMP NSOR WITH AUTO PUMP SHIT OFF AUDIBLE AND VISUAL ALARMS ALARMS 015. AUTOT%IATiC LtNF LEAK DETECTOR (3.0 GPH TEST) WITHOUT FLOW 0 15.AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST) SHUT OFF OR RESTRICTION ❑16. ANNUAL INTEGRITY TEST(0.)GPH) ❑16.ANNUAL INTEGRITY TEST(0,1 GPH) []17. DAILY VISUALCHECKE]17. DAILY ViSUAL CHECK VIII._DISPENSER CONTAIN_NIF:N_T_ SER CONTAINMENT 468. ❑L FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE a, DAILY VISUAL CIJ1 CK 469. �-DISPEN--- --- DATE INST Ell 0 2. CONTINUOUS DISPENSER PAN SENSOR+AUDIBLE AND VISUAL ALARMS ❑5. TRENCH/LINER MONITORING ❑J. CONTINUOUS DISPENSI--R PAN SENSOR WI' AUTO SiRIT OFF FOR ONE DISPENSER+AUDIBLE AND VISUAL ALARMS IX OWNER/OPERATOR SIGNATURE i 1 ccrtif the info tion provided herein is c and accurate to the hest.of my knowledge. 470 C/ 472. q TOWNER/,QPWT (print): TITT E OP O�T1F,R/OPERATOR: tt �w 4.rA. (a to elm Permit Number(Reercy tree only) 473. Permit Approved By(Agency use only) 474 Permit Expiration Date(AFer4 y use only) 475. Rev.02/10/00UPCF Llwfwrc-h(1/94)-3114 http://www.Unidnes.org