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UNIFIED PROGRAM CONSOLIDATED FORM TANKS UNDERGROUND ST® GE TANKS-TANK PAGE 2 .Pae Of Vi.PIPING CONSTRUCTION CI.kall Ilun yl UNDERGROUND PIPING A90VEGROUND PIPING SYSTEM TYPE .PRESSURE. ❑2.SUCTION ❑3.GRAVITY 458. ❑1.PRESSURE ❑2.SUCTION ❑3.ORAV ITY 459. CONSTRUCTION/ ❑I. GLE WALL ❑3.I..TNED TRENCH ❑99.OTHER 460. ❑1.SINGLE WALL ❑95.UNKNOWN 462, MANUFACTURER DOUBLE WALL ❑95.UNKNOWN ❑2.DOUBLE WALL ❑99.OTHER MANUFACTURER k Q• 461. MANUFACTURER 463. ❑I.BARE STEEL, ❑6.FRP COMPATIBLE W/100%METHANOL ❑1.HARE STEEL ❑6.FRP COMPATIBLE W/IOD"/METHANOL ❑2.STAINLESS STEEL ❑7.GALVANLzrm STEEL [12.STAINLESS STEEL ❑7.GALVANIZED STEEL. ❑3.PLASTIC COMPATIBLE WITH CONTENTS ❑95-UNKNOWN [13.PLASTIC COMPATIBLE W/CONTENTS ❑R.FLEXIBLE(HDPE) ❑99.OTHER ❑4.FIBERGIASS ❑8.FLEXIBLE(HDPE•) ❑99.OTHER [14.FIBIRGLASS ❑9.CATHODIC PROTECTION ❑5.STEEL W/COATING ❑9.CATHODIC PROTECTION 4(A. ❑5.STEEL.W/COATING ❑95.UNKNOWN 465. V IL PIPING LEAK DETECTION(Cheek alt ttm+ y)(A dt eription o f the nwmilorin gram slwll be xubtrined to the k=(a y. lINDERGROTJND PIPING A" 46k PIPING SINGLE WALL PIPING 466. SINGLE WALL.PIPING 467' PR�5,9URI7BD PIPING((heck all tlnc apply?= PRESSt)RI7.E1)PIPING(Chemic seVl tkttPIy): l^y'1! ELECTRONIC LINE LEAK DETECTOR 3.0 C�'1i Th ST WITH AUTO PUMP ❑1. F.I.RCl'RONIC LINE LEAK DETECTOR IA GPH TEST WITH AUTO PUMP S1I1T-OFF FOR LEAK.SYSTFM FATIdJRT:,AND SV STEM DISCONNECTION SHATOTF FOR LF.AK,SYSTEM FAILURE,AND SYSTEM DISCONNECTION +AUDIBLE AND VISUAL ALARMS. +AUDIBLE AND VISUAL ALARMS. ❑2. MONTHLY 0.2 GPH TEST ❑2. MONTHLY 0.2 GPH TEST []3. ANNUAL TNTFCTRITY T&9T(n.1 GPH) ❑3. ANNUAI.INTEGRITY TEST(0.1 OPH) 04- DAILY VISUAL CHECK CONVENTIONAL SUCTION SYSTEMS CONVENTIONAL SUCTION SYSTEMS(Check all that apply) ®5. DAILY VISUAL MONITORING OF PUMPING SYSTEM+TRIENNIAL PIPING [35. DARY VISUAL MONITORING OF PIPING AND PUMPTNG SYSTEM INTEGRITY TEST(0-1 GPH) SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): [16. TRIENNIAL INTEGRITYTEST(0.)GPH) ❑7. SELF MONITORING SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING),. GRAVITY FLOW ❑7. SELF MONITORING ❑9. BIENNIAL INTEGRITY TLST(0.1 GPII) GRAVITY FLOW(Check nil that apply): [38, DAILY VISUAL.MONITORING ❑9. BIENNIAL INTEGRITY TEST(0.1 CPR) SECONDARILY CONTAINED PIPING SECONDARILY CONTAINED PIPING PRESSURIZED PIPING(Check all that apply): PRESSVRIZED PIPING(Check all that apply). 10. CONTINUOUS TURBINE_ SUMP SENSOR WUTH AUDIBLE AND VISUAL 10. CONTINUOUS TURBINE. SUMP SENSOR WITH AUDIBLE AND VISUAL A^LAlRMS AND(Check one) At AND(Check ane) (Ib a- AUTO PUMP SIWI'OFF W I3EN A LEAK OCCURS ❑u. AUTO PUMP'ALIT OFF WHEN A LEAK OCCURS ®b.AUTO PUMP SI1UT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM ❑b.AUTO PUMP SHUT OL"T FOR LEAKS,SYSTEM F•ARA)RL•AND SYSTEM DISCONNECTION DISCONNF.C'TION 01,11" � ❑c. NO AU-TO PUMP SHUT OFF ❑c. NO AUTO PUMP SIRIT OPF [H,1 AUTOMATIC LINE LEAK DETECTOR(3-0 GPH TEST)WITH FLOW SHUT ®1).AUTOMATIC LEAK DGTTCTOR OFF OR RESTRICTION 12, ANNUAL INTEGRITY TEST(0.1 GPH) ❑12.ANNUAL INTEGRITY TESTt0.1 GPIs) SUCTION/GRAVITY SYSTEM STJM- ON/GRAVITY SYSTEM ❑13. CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS ❑11.CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL:ALARMS EMERGENCY GENERATORS ONLY(Check aU that apply) EM F,R('MNCY GENERATORS ONLY(Check all that apply) 1114. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF ®14.CON11LFIOND VISUAL NSOR WM40UT AUTO PUMP SHUT OFF AUDIBLE AND VISUAL ALARMS ❑15. AUTOMATIC LINE LEAK DETECTOR (3.0 GPH TEST) WITHOUT FLOW ❑15.AUTOMATIC LIVE LEAK DETECTOR(3.0 GPH TEST) SHUT OFF OR RESTRICTION i C]16. ANNUAL INTEGRITY TEST(O.1 GPH) ❑16.ANNUAL INTEGRITY TEST(0.1 GPH) ❑17. DAILY VISUAL CHECK 1 ❑17. DAILY VISUAL CHECK. VIII.DISPENSER CONTAINMENT -----_- - ---------.-------..._._..._._-____---------------•-__.__ __ -- DAILY VISUAL CHECK 469. DISPENSER CONTAINMENT 468. El 1. FLOAT MEC14ANISM THAT SHUTS OFF SHEAR VALVE - DATE INSTA Ell ❑2. CONTINUOUS DISPENSER PAN SENSOR+AUDIBLE AND VISUAL ALARMS ®5. TRENCHILINER MONITORING [3 1. CONTINUOUS DISPLNSI--R PAN SENSOR WITH AUTO SHUT OFF FOR Qf,-NONE DISPENSER AUDIBLE AND VISUAL ALARMS DL OWNERIOPERATOR SIGNATURE I certify the i cin is true and accurate to the(lest of my knowledge. a70. �MK --4!52� 472. EO f�W�J /OP: T V i t): 7171.F OF WNF.R/OP RAT R;I n r Permit Number(Agency tttte only) 473. Permit Approved By(Agency use on 474 1 PCCrrM(Expiration Date(Agency me only) 473. UPCI'hwfwre-h(1199)-3/4 http://www.unidncs.org, Rev.0211(1/00