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f UNIFIED PROGRAM CONSOLIDATED FORM TANKS UNDERGROUND ST® GE TANKS-TANK PAGE 2 Pae of V1.PIPING CONSTRUCTION Cluck niltbat UNDERGROUND PIPING ABOVEGROUND PIPING SYS EM TYPE FRESSURE ❑2.SUCTION [❑3.GRAVITY 458. [j1.PRESSURE ❑2.SUCTION (:13.GRAVITY 459. CONSTRUCTION! ❑1,SINGLE WALL ❑3.LJNED TRENCH [199.OTHER 46o. ❑1.SINGLE WALL ❑95.UNKNOWN 462. MANUFACTURER j6OUBLEWALL ❑95.UNKNOWN ❑2.DOUBLE WALL ❑99.OTHER MANUFACTURER •�• ( 461. 1 MANUFACTURER 463. ❑1.HARE MEL ❑6.FRP COMPATIBLE W/I(XM METHANOL ❑1.HARE STEEL ❑6.FRP COMPATIBLE W/100"/METHANOL ❑2.STAINLFSS STEEL ❑7.GAI..VANI7.FD STFFI. [12.STAINLESS STEEI, ❑7.GALVANIZED STF,EL. ❑3.PLASTIC COMPATIBLE WITH CONTENTS ❑95.UNKNOWN ❑3.PLASTIC COMPATIBLE W/CONTENTS ❑R.FLEXIBLE(HDPE) ❑99.OTHER ❑4.FIBERGLASS ❑A.FLEXIBLE(HDPE) ❑99.OTHER [14.FIBERGLASS ❑9.CATHODIC PROTECTION ❑5.STEEL W/COATING ❑9.CATHODIC PROTECTION 4(t4. ❑5.STEEL W/COATING ❑95.UNKNOWN 465. V IL PIPL'NG LEAK DETECTION(Check aIt liwt n )(A deseri -n of the namd6rin clwli ix sul ucd to the lactl a y. IINDFRGROUND PIPING ABOVEGROUND PIPING SINGLE WALL PIPING 4(K+ SINGLF WALL PIPING 467. PRES�SURI7BD PI'ING(Check all that nPP1yY PRESSURIZED PIPING(Ch-,+-11 0W apply)-- (�y�l/ ELECIRONIC LINE LEAK DETECTOR 3.D GPIJ TfiST WITH AUTO PUMP 01. FLW71 LINE LEAK DETECTOR .0 C9PH TEST WITH AUTO PUMP SHI1T-OFF FOR LEAK,SYSTEM FAIIIIRE,AND SYSTEM nISCONNF.CTiON SMIT OFF FOR I.FAK,SYSTEM FAILURE,AND SYSTEM DISCONNECTION +AUDIBLE AND VISUAL ALARMS. +AUDI ELE AND V ISUAL ALARMS. [12. MONTHLY 0.7 GPR TEST ❑2. MONTHLY 0.2 CPU TEST 1 1 [13. ANNUAL INTF.0RtTY TEST(0.1(}PH) ❑3. ANNUAL.INTEGRITY TEST(0.1 OPFI) ❑4. DAILY VISUAL CHECK CONVENTIONAL.SU(`now SYSTEMS CONVENTIONAL SUCTION SYSTEMS(Cheat nil that apply) ❑5. DAILY VISUAL MONITORING OF PUMPING SYSTEM+TRIENNIAL PIPING [35, DAI,Y VISUAL MONITORING OF PIPING AND PUMPTNG SYSTEM INTEGRITY TEST(0.1 GPM) SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): ❑6. TRIENNIAL INTEGRITY TEST(0.I GPH) ❑7. SELF MONITORING SAFE SUCTION SYSTEMS(NO VALVFS IN BELOW GROUND PIPING): GRAVITY FLOW ❑7. SELF MONITORING. ❑9. BIENNIAL INTEGRITY TEST(0.1 GPH) GRAVITY FLOW(Check all that apply): ❑R. DAILY VISUAL.MONITORING [19. BIENNIAL INTEGRTry TEST(0.1(iPli) SECONDARILY CONTAINED PIPING SECONDARILY CONTAINED PIPING PRESSURI7_ED PIPING(Check all that apply): PRESSURIZED PIPING(Check all thnt appiy). 10. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL. 10. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL ALAjRMS AND(Check one) ALARMS AND(Check one) W a AUTO PUMP Sinn-OFF WHEN A LEAK OCCURS ❑u. AUTO PUMP SITUI OFF WITEN A LEAK OCCURS ®b.AUTO PUMP SIAJT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM ❑b.AUTO PUMP SHUT 01-T FOR LEAKS,SYSTEM FAILURE AND SYSTEM DISCONNECTION DISCONNECTION ❑c. NO AUTO PUMP SIRIT OFF ❑c. NO AUTO PIJMP SInrT OPF 11. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)WITH FLOW SHUT ®11 AUTOMATIC LEAK DETECTOR OFF OR RESTRICTION ❑12. ANNUAL INTEGRITY TEST(0.1 GPM) ❑12.ANNUAL INTEGRITY TEST(0.1 GPH) SUCTIONIGRAVITY SYSFE164 STICFIONICRAVITY SYSTEM ❑13. CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS ❑".CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL,ALARMS EMERGENCY GENERATORS ONLY(Check all stmt app)y) EMERGENCY GENERATORS ONLY(Check nll 11"1"171`10 1-114. CONTINUOUS-,Ij%1P SENSOR WITHOUT AUTO PUMP SHOT OFF ®14.CONTINUOUS OND StIMP UAL ALARMS 015, AUTO PUMP%MJT OFF AUDIBLE AND VISUAL ALARMS ❑15. AUTOMATIC LINE LEAK DETECTOR (3.0 GPM TEST) WITHOUT FLAW ®15.AUTOMATIC LINE LEAK DETECTOR(3.0 GPM TEST) SHUT OFF OR RESTRICTION C]16. ANNUAL INTEGRITY TEST(0.1 GPM) ❑M.ANNUAL INTEGRITY TEST(0.1 GPM) [317. DAILY VISUALCHECK ❑17. DAILY VISUAL CHECK. VIII.DISPENSER CONTAINMENT DISPENSER CONTAINMENT 468. ❑1. FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE ^� ~' 1)A11Y VISUAL CHECK 469. DATE INSTA Ell ❑2. CONTINUOUS DISPENSER PAN SENSOR+AUDIBLE AND VISUAL ALARMS 0 5. TRENCH/LINER MONITORING ❑3. CONTINUOUS DISPLNSPR PAN SENSOR WITH AUTO SLUT OFF FOR @J.-NONE DISPENSER+AUDIBLE AND VISUTAL.ALARMS IX.OWNF.R/OPERATOR SIGNATURE I certify the i ein i5 true and accurate to the hest of Tny knowledge. a �6�9 7o. 412. AME OT•/,jW�NT1RrOP: T i t): T17T.F OF WNFR/OP RAT R:,N Permit Number(Agency leve only) 473. Permit Approved By(Agency use only) 474. 1 Permit Expiration Date(Agency use only) 475. UPCF bwfwrc-b(1/99)-304 htip://www.unid",%.atg Rev.02/16/00