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<br />UNIFIED PROGRAM CONSOLMATEp VORM
<br />UNDERGROUND ERGROUND STORAGE TANKS - T_ INK PAGE 2
<br />LNAERGILCUNdD PIPrI40
<br />SYSTEM T'03 I. PRres=Jkr' 02 SUCTION
<br />c0?t37RL'CT SZ;GLE WALL Q 3. L.'NED TRENCH
<br />W,V 1l FACTU R DOUBLE WALL ❑ M. UNKNOWN
<br />3.CR1'IT"j 4S3 j I]1.?RESSLPE El2. SUCTION
<br />19. CTHER 440 ❑ 1. SINGLE WALL
<br />❑ 2. DOUSLE WALL
<br />461 i I$ANUFACTL'RER
<br />j ❑Lr'ARFSTB 1-
<br />2.
<br />3. ST^INLEISS STEEL
<br />❑ 3. PL4S71C C JMPATL'i: w' +70N 'IS
<br />❑ 4. FI ZRCLASS
<br />Eli. STEEL W/COATL14C,
<br />❑ I. BARE STEEL ❑ 6, FRP COMPAT(OLg wAoan MPT&1NOL
<br />❑ 2, STAINLESS STEEL ❑ 7. C l;. VA D STEEL [3 V known
<br />mPLASTIC (;QM?ATMLE `+4'/ CONTB TS ❑ 99 Cthet
<br />I� ?BERGLa' S p 3: FL7-VaLE;;KDPE)
<br />V 577i?;? 'A/ Oi>TUVG ❑ 9, CATHODIC PROTtCTION 444
<br />SLATELZ WALL PIPl!rVG 4&
<br />PRE557J UM ?]?NO- (chrA an dce gplyl:
<br />p 1 FLkCTROMC LINE L ,W MECrOR 3.0 OPS TIMIT ;)L= AUTO PLW 511VT
<br />OFF FOR LEAK, SYSTEM FAILURE, AND SYSTEM DLSCOWEC11ON
<br />AUDIBLE AND VISUAL ALARMS.
<br />0 2. MONTHLY 02 GfH TEST
<br />0 3. ANWAL INTEGRITY TEST (L1ICPR)
<br />CONVENT70N F,5UCTIONSYSTFAS
<br />© 5. D.vlt'! VISUAL MON?1TCRLNG qF PUMP.TrIG S'YSTEhI - TA.IEri'hT,tL PTPJNG
<br />IN?EoFxrfTEST (0.1 GAA)
<br />SAFE SUCTION 5YSTINS (NO V>LUSS LV BILOW CR04".vOFIPING);
<br />[17, SELF MONITORING
<br />GRAVITY FiOW
<br />C 0.519NmAi r . c;uTY TEST (0.1 GFH)
<br />SECONDARILY CONTADMI) PIPING
<br />PRESSURIZED PIPING (Check au Mapply)
<br />10. CCN"TINUOUS TURBWE SUNIP SEN'SOR'91TR AI;D18L8 AND VISUAL
<br />.L *, W S AIV' D (L1wk ate)
<br />74 A'-?0I'..'MP SHUT OFF WHENA LEAXOCCLRa
<br />p h AUTO PUMP SH'_? OFF FOR LEAK$, RVgT '.M FAILURE, AND SY3*,oX I
<br />DISCONNECTION
<br />EIC. NO AUTO PUA{P S1= OFF
<br />U. A U T 0 1 vLATIC L1i4F, LEAK DETECTOR (3.0 GPIs 7EST) VV NII FLOP: gR1,7
<br />OFF ORREST L)C ION
<br />A2. ANNUAL IN; EORITYTEST (0.1 GPI)
<br />SUCTIONIGRAVITY SYSTEM
<br />❑ 13, CONTINUOUS &OUF SENSOR +AUDIBLY AID VISUAL ALARMS
<br />101.0tGENCY GENERATORS ONLY ;Cb"k a9 :hxl npp11)
<br />Li 14, CONTINUOUS SUMP SENSOR WTMOtrr AUTO FUMP :HUT OFY `
<br />AUD:YiLb AiYD VI.N-IIAL ALARMS
<br />IS. AUTOMATIC LINE LEAK D'CTFCTOR (3.0 GPH TEST] Xmojz. FLOW
<br />51 -"UT OFF OR RESTRICTION
<br />❑ L6. ANNUAL TNTEGa1TY TEST ((LI GPH)
<br />Q IT DAILY VISUAL CHECK
<br />TA.ti'ICS '
<br />i
<br />1w --
<br />. GRAVITY 43
<br />❑ 95. Ur"r-TOWN , a
<br />❑ 94. GTHEI.
<br />iv
<br />❑ 6, FRP COMPA T ESLL ti'II DC3( N(F TW NOL
<br />❑ 7. GALVANIZED S'rHEL
<br />[] 9. FLEh7HLL• ❑ 99, 07 qEr,
<br />❑ 9. CBAT?GDIC ?P'oT'z-Y7:ON
<br />❑
<br />0. •jMCN-OWN 465
<br />SlINGLE WALL PIPING 467
<br />PRESSL'RIZE'Z P1PING' .C'I* kaR th,-wph-F
<br />❑ ;, ELECTRCin1CL1N? LE,iKDL�'fP.CTOP,3.OvF:iTESTyi:Lt.:L'Tilml�tc
<br />SHUT Of FOR Lr -AK. SYSM( FIJLURE, AND SYSTEM WCOvi'E TION
<br />AUDIBLE AIM VISUAL AL\AMS,
<br />Q 2. MCNTHLY 0.2 CPR T*.!$T
<br />❑ 3. ANNUAL INTEGRITY T -ST ((j, i GPH)
<br />C 4, DAILY VISUAL CT1ECK
<br />COivYBNr.ONAL SLC7181; SYSTEMS (Clsvk a i Qul ;upjy)
<br />❑ S. DA.MY V18U.--L MONROP.Th?C, OPPEPLNG AND PM &` -NQ,
<br />❑ 6. TRIL?NIAL, DTEMU rl TESY (1.1. GPH)
<br />SAF- SL'CP,CN SYSTEMS (NO VALVss Iva %OW GROL?'D PIPING):
<br />❑ 7. SELF MONITORING
<br />GRAVITY FLOW tG're!: au %hpi P'Wp Y1;
<br />❑ & r.,%TLY VISI,;AL IdO: 0PLE,4G
<br />Q 9. BaNNIAL INTEGRITY T'JST (0,1 GPH,
<br />SECOND.4l1LY CONTAINED rII i VG
<br />PRESSU,'UZED PEPENG (1 tack an that aoplrJt
<br />l0. CONMMUDUS TURIVNE SUMP SENSOR u'�T}j AUDIBLE AND VISLAL
<br />ALAR*AIS AND (Owckaaa)
<br />❑ e AUTO PIN? SHLT OFF WHEN A LEAK OCCURS
<br />❑ h AI,)TO PL's IP SHUT OFF FOR LEA.K9, 5YS7'Em FAILL'1t'- AND $YSTEM
<br />DISCONNECTION
<br />Cc NO A= PUMP SHUT OFF
<br />11. AUTOMATIC LBAX!)eTBCTOR
<br />[�
<br />11, ANNUAL INTEGL'TY TEST (0.1 GPH)
<br />aUCT10N,CR,tV1TV SYSTE'tii
<br />❑ 13. C0N7TT,PJ0L'S SL'I.tP SENSOR+AUDIBLE AND V1SL'.A-L ALAILMS
<br />EMERGENCY rgT1wrRATOR:5 OnY (Cnwk .0 IYat u:!rl
<br />❑ 14, GONTII� JOC%S SUMP ScI�'SGR u' n� A1ST0 PC; `P ' SHt;T OF:
<br />AUDIPILE XD VISLAL AL :1RA75
<br />j ❑ I
<br />S. ALTONJATIC LNE LEAK DETI CTOIL (3.0 GI°H -"T)
<br />❑ 16. ANNUAL INTEGRITY TEST (3.1 GPn)
<br />❑ 17. DAILY VISUAL CHECK
<br />VXIL DLiPEYSER CONTAW-NnNIT w
<br />DISPENSEEt COLNTANMENT . FLOAT MECRAMSM 71iAT SWT -1,0" SHEAR VALVE [14. 0AILY viSUAL CHICK
<br />DATS INSTALLED 4U ❑ 2. CONTLNUOUSDMPENSSR PAN SENSOR AUDIBLE A,1W VISUAL ALARMS [3 2. TRENCYi LWER; &IONITORING
<br />\ ❑ 3. CONTINUOUS DISPENSER PAN SENSOR mj-jE ,VM SHUT OFF FOR p 5 :HONE 4at1
<br />VC DISPEN9rR , AUDIBLE AND'T79UAL ALAFLMS
<br />IX. OPiNERJOFEILITOR SIGNATURE j
<br />t xAai(y IFat tiv IIs(aelaalk» Provided neralp � �ea rAi .a..et. w tlAe Met oiArry ktowledar. �
<br />$IGNAT O OR DAT*_ 4k)
<br />�� �_/%A__
<br />J2-
<br />473
<br />Z
<br />473 P -it AM -4 (for ivwl we anty) 474 Permit IIpirlden Dm4(Fac kcal
<br />UPCF (i "/ revised) 12 Formerly 51VTcCB Felm B
<br />
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