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UNIFIED PROGRAM CONSOLIDATED FORM TANKS 'UNDERGROUND STORAGE TANKS-TANK PAGE 2 Page of VI.PIPING CONSTRucr7460. -wirallthat UNDERGROUND PIPING ABOVEGROUND PIPING sY4TEM TYPE I,PRESSURE ❑2.SUCTION ❑3.GRAVITY58. ❑1.PRESSURE ❑2.SUCTION ❑3.ORAVITY 4s9. CONSTRUCTION/ p 1.SINGLE WALL ❑1.LINED TRENCH ❑99.OTHER ❑1.SINGLE WALL ❑95.UNKNOWN 462. MANUFACTURER 162 DOUBLE WALL ❑95.UNKNOWN ❑2.DOUBLE WALL ❑99.OTHER MANUFACTURER t Q,5mvr 461. MAMIFACTURER 4h3. ❑ I.BARE STF,I:I, ❑6,FRP COMPATIBLE,W11(X0%METHANOL ❑1,BARE STEEL ❑6.FRP COMPATIBLE W/100 METHANOL ❑2_STAINLESS STEEL ❑7.GATMANI7m)STEEL El 2.STAINLESS STEEL ❑7.GALVANIZED STF,EL MVPLASTIC COMPATIBLE..WITH CONTENTS ❑95.UNKNOWN ❑3.PLASTIC COMPATIBLE W1 CONTENTS ❑R.FLEXIBLE(HDPE) ❑99.OTHER 4.FIBERGIASS ❑R.FLEXIBLE(HDPE) ❑99.OTHER [14.FIMAGLASS ❑9.CATHODIC PROTECTION ❑5.STEEL W/COATING ❑9.CATHODIC PROTE('L'ION 464. I ❑5.STET[.W/COATING ❑ 95.UNKNOWN 465. VII.PIPING LEAK DETECTION 1Chcck all that v)(A description of the nmiloring pmnT sliall be aubtnitled to the loch,a y. 11NDFRGROIIND PIPINGABOVL•GROUND PIPING SINGLE WALL PIPING a6h SINGLE t4'AL1.PIPING 467. PRURI2..F,D PIPTNG(Check ail tint apply)- PRESSURIZED PIPING.(CAekik all that applyY ). ELECTRONIC LINE LEAK DETECTOR 3A GP1T T FST WITH AUTO PUMP ❑1. EI.W-IRONIC TINE LEAK DETECTOR 3.0 GPM TEST WITH AUTO PUMP SHIIT-OFF FOR LEAK,SYSTEM FATIVRL•,AND SYSTEM DISCONNECTION SHUTOFF FOR LEAK,SYSTEM FAILURE,AND SYS TF..M DISCONNECTION +AUDIBLE_AND VISUAL ALARMS. +AUDIBL T;AND VISUAL ALARMS. ❑2. MONTHLY 0.2 GPM TEST [12. MONTHLY 0.2 GPH TEST ❑3. ANNA AT,INTEGRLTY TeST(0.1 arm) ❑3. ANNUAL.INTEGRITY TEST(0.1 OPM) 04. DAILY VISUAL CHECK CONVENTIONAL SU(`ITO)VSYSTEMS CONVENTIONAL SUCTION SYSTEMS(Check nll that apply) ❑5. DAILY VISUAL MONITORING OF PUMPING SYSTEM+TRIENNIAL PIPING ®5 DAH Y VISUAL.MONITORING OF PIPING AND PITMPTNG SYSTEM Th7EGRTIY TEST 40.1 GPM) SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): ❑6. TRIENNIAL INTEGRITY TEST(0.1 GPM) ❑7, SELF MONITORING SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPINGY. GRAVITY FLOW ❑7. SELF MONITORING ❑9. BIENNIAL INTEGRITY TEST(0.1 GPM) GRAVITY T-1,01W(Check all that apply): ❑R, DAILY VISUAL MONITORING []9. BIENNIAL INTEGRTTV TEST(0.1(iPIT) SECONDARILY CONTAINED PIPING SECONDARILY CONTAINED PIPING PRESSURMLI)PIPING(Check all that apply): PRESSURIZED PIPING(Check all that apply): 10. CONTIM)OUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL 10. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL ALARMS AND(Check one) AT.ARMS AND(Check ora) a.AUTO PUMP SMUT OFF WREN A LEAK OCCURS ❑u.AUTO PUMP SHUT OFF WHEN A LEAK OCCURS b.AUTO PUMP SIR)T OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM ❑b.AUTO PUMP SHUT 01-T MR LEAKS,SYSTEM FAII.URL•AND SYSTEM DISCONNECTION I DISCONNECTION ❑c. NO AU'f0 PUMP Si1UT OFT ❑c. NO AUTO PUMP SII11T OFF [�11. AUTOMATIC LINE LEAK DETECTOR(3.0 GPM TEST)WITH PLOW SHUT ®1).AUTOMATIC LEAK DETECTOR OFF OR RESTRICTION ❑12. ANNUAL INTEGRITY TEST(OA OPH) "1 ❑12.ANNUAL INTEGRITY TEST(0.1 GPIs) SUCTION/GRAVITY SYSTEM SUCTIONIGRAVITY SYSTEM ❑13. CONTINUOUS STIIvIP SENSOR+AUDIBLE AND VISUAL ALARMS ❑11.CONTIMJOUS STIMP SENSOR+AUDIBLE AND VISUAL ALARMS EMERGENCY GENERATORS ONLY(Check all that apply) EM FRt:FiiCY GENERATORS ONLY(Check all that apply) ❑14. CONIIN•tIOUS SI;T%fp SENSOR WITHOUT AUTO PUMP SHUT OFF ❑14. AUDlB.IMP OANA VISUAL ALARMSSOWMiOUT AUTO PUMP SMTIT OFF AUDIBLE AND VISUAL ALARMS ❑15. AUTOMATIC: LINE. LEAK DETECTOR (3.0 GPM TEST) WITHOUT FLOW ®15.AUTOMATIC LINE LEAK DETECTOR(3.0 GPM TEST) SHUT OFF OR RESTRICTION ❑16. ANNUAL INTEGRITY TEST(0.1 GPM) ❑16.ANNUAL INTEGRITY TEST(0.1 GPM) ❑17. DAILY VISUALCHECK ❑17. DAILY VISUAL CHECK. VIII.DISPENSER CONTAINMENT r__DISPENSER CONTAINMENT 468. ❑1. FLOAT MECHANISM THAT SHUTS OFF S14L,VALVE � 4, DAILY VISUAL CHECK 469. __.______ !�_ DATE INSTALLED p'tS ❑2. CONTINUOUS DISPENSER PAN SENSOR+AUDIBLE AND VISUAL ALARMS 05. TRENCH/LINER MONITORING ❑3. CONTINUOUS DISPENSIiR PAN SENSOR W1311 AUTO SIRIT OFF FOR bi'"� NONE DISPENSER+AUDIBLE AND VISUAL ALARMS mo I%.OWNERIOPERATOR SIGNATURE I cc the inf !tion provi herein is true an accurate m the hest of my knowledge. azo /OPERAT C v 472. TITT E OF OWNER/OPERATOR: NAME OF WN•R/ PT �RATOR int): Q W r-+ I f a- - Permit Numhe:(Agency 1,ve only) 473. Permit Approved By(Agency use only) 474. Permit Expiration Date(Agency ticc only) 475. UPCF hwNrc-b(1199)-3/4 http://www.unidoes.atg Rev.02/16/00