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UNIFIED PROGRAM CONSOLIDATED FORM TANKS 'UNDERGROUND STORAGE TALKS-TANK PAGE 2 Pae of VI.PIPING CONSTRUCTION Cieckalltltat, UNDERGROUND PIPING ABOVEGROUND PIPING SYSPF,M TYPE1.PRESSURE ❑2.SUCTION ❑3.GRAVITY 458. O L PRESSURE ❑2.SUCTION ❑3.ORAVITY 459. CONSTRUCTION/ 0 1,SINGLE WALL ❑3.1..TNED TRENCH ❑99.OTHER 460. ❑L SINGLE WALL ❑95.UNKNOWN 462. MANUFACTURER Z2 RUBLE WALL ❑95.UNKNOWN ❑2.DOUBLE WALL ❑9q.OTHER MANUFACTURER +'ll . 461. MANUFACTURER 463. D.I.HARE STEEL, ❑6.FRP COMPATIBLE W/IWYYf METHANOL ❑1.HARE STEEL ❑6.FRP COMPATIBLE Wil 0(r/.METHANOL ❑2.STAINLESS STFFL ❑7.GAL,VANI7.FD STEEL ❑2.STAINLESS STEEL ❑7.GALVANIZED STEEL ❑3.PLASTIC COMPATIBLE WITH CONTENTS ❑95-TINKNOWN ❑3.PLASTIC COMPATIBLE W/CONTENTS ❑8,FLEXIBLE(HDPE) ❑99.OTHER ❑4.FIBERGLASS ❑8.FLEXIBLE(HDPE) ❑99-OTHER ❑4.FIBERGLASS ❑9.CATHODIC PROTECTION ❑5.STEEL W/COATING p 9.CATHODIC PROTECT ®6a. ❑5.STEEL,WlCOATtNG ❑95.UNKNOWN 465• VII.PIPING LEAK DETECTION(Check all 11.1 )(A deseti n a f the tttrnttlari cltall be sut tttiucd to the be tl a y. UNDERGROUND PIPING AHOVEGROUND PIPING SINGLE WALL.PIPING 4W SINGLE WALL.PIPING 467. PPR,/E�9.4UR17-.F,D PIPING(Check all thatapply): PRESSTUR17.ED PIPING(Check tell 11-ti aPPIYk 1. ELECTRONIC LINE LEAK DETECTOR 3.0 GPIs TEST WITH AUTO PUMP 01. ELECTRONIC LINE LEAK DETECTOR:t.0 GPH TEST WITH AUTO PUMP SHUT-OFF FOR TEAK,SYSTFM FAILURE:,AND SYSTF,M OISCONNF.CTION SIT!IT OFF FOR T.FAK,SYSTEM FAILURE,AND SYSTEM DISCONNECTION +AUDIBLE:AND VISUAI.ALARMS. +AUDIBL F.,AND VISUAL ALARMS. ❑2- MONTHLY 0.2 GPH TEST ❑2. MONTHLY 0.2 GPH TEST i ❑3. ANNUAT,rNTF,GRtTY TEST(O.t OPH) ❑3. ANNUAL.INTEGRITY TEST(0.I OPH) 04. DAILY VTSUALCHECK CONFVL+NTIONAI.SUCTIOTI SYSTEMS CONVENTIONAL SUCTION SYSTEMS(Check all that apply) ❑5. DAILY VISUAL MONITORING OF PUMPING SYSTEM+TRIENNIAL PIPING ®5, DAn-Y VISUAI.MONITORING OF PIPING AND PUMPING SYSTEM INTEGRITY TEST(0.1 GPA) SAFE SUCTION SYSTEMS(NO VALVFS IN BELOW GROUND PIPING): []6. TRIENNIAL INTEGRITY TFS"f(O.I GPH) ' p 7. SELF MONITORING SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): GRAVITY FLOW p 7. SELF MONITORING ❑9. BIENNIAL INTEGRITY TEST(O.1 GPH) GRAVITY FLO%V(Check all that apply): ❑R. DAILY VISUAL MONITORING ❑9. BIENNIAL INTEGRITY TEST(0.1 GPH) SECONDARILY CONTAINED PIPING SECONDARILY CONTAINED PIPING PRESSURI7.ED PIPING(Check ail that apply): PRF,SSURI7,ED PIPING(Check all that vpply): 10, CONTINIOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL 10. CONTINUOUS TURBINE SUMP SENSOR WITH At/DfBLE AND VISUAL AI. MS AND(Check one) At ARMS AND(Check one) AUTO PUMP STTITT OFF WHEN A LEAK OCCURS ❑u.AUTO PUMP SHUT OFF WITEN A LEAK OCCURS ❑ It.AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM p b.AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM DISCONNECTION DISCONNECTION �❑c. NO AUTO PUMP SINT OFF pc. NO AUTO PUMP sinIT OFF M4 AUTOMATIC LINE LEAK DETECTOR(3.0 GPII TEST!WITH FLOW SHUT ❑11.AUTOMATIC LEAK DE17:CTOR OFF OR RESTRICTION p 12. ANNUAL INTEGRITY TEST(0.1 GPH) ❑12.ANNUAL INTEGRITY TEST(0.1 GPH) SUCTION/GRAVITY SYSTEM SUCTION/GRAVITY SYSTEM ❑13. CONTINUOUS SUMP SENSOR+AUDIBLE.AND VISUAL ALARMS ❑1.1.CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS ` EMERGENCY GENERATORS ONLY(Check ai)that apply) FMFR(:F1.4CY GFNFRATORS ONLY(Check al)that apply) []14. CONTINUOUS STIMP SENSOR WITHOUT AUTO PUMP SPOT OFF ❑14. CONTINIOUS SUMP SENSOR WIT14OUT AUTO PUMP SHUT OFF AUDIBLE AND VISUAL ALARMS AUDIBLE AND VISUAL ALARMS ❑15. AUTOMATIC; TmtE: 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) 017. DAILY VISTUAL CHrCK p 17. DAILY VISUAL CHECK. Vill._DISPENSER CONTAINMENTDI SPENSER CONTAINMENT 468. ❑1. FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE 4• DAILY VISUAL CHECK --469. DATE INST Ell ❑2. CONTINUOUS DISPENSER PAN SENSOR+AUDIBLE AND VISUAL ALARMS [35. TRENCH/LINER MONITORING [33. CONTINUOUS DISPENSER PAN SENSOR WI' AUTO SENT OFF FORrt/EINE DISPENSER+AUDIBLEANDVISUA.L ALARMS fit' `� IX OVYNER/OPERATOR SIGNATURE I ccrtif Ute in tion provided herein is uc and arctlrate to the best.of Tnv knowledge. azo. no -149 a72. AMFOF WNEg/,QPF AT (print): T111.1OFOWNF,RIOPERATOR: WQ W llt er Permit Number(Agency uxe only) 473. Pertrit Approved By(Agency use only) 474 1 Permit Expiration Date(Agemy use only) 475. UPCF hwfwre-h(1194)-3/4 hall://www.unidncS.ofg Rev.02/I0/00