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UNIF15 PROGRAM CONSOLTAXFE-D- <br />FORM <br />TANKS <br />UNDERGROUND STORAGE TANKS - TANK PAGE 2 <br />-V PaAe Of <br />r. �IMNM�t �(�,N: <br />UNDERGROUND PIPING <br />ABOVEGROITNDPIPLNG <br />SySrEMTIYPE 4TI. PRESSURE 0 7- SUCTION 0 3. GRAVITY 459. 0 1. pREssukE 0 2. SUCTION [13. GRAVITY 459. <br />CONSTRUC"�ON/oI �STKGL7E WALT. 0 3. LtNEv TRENCH 0 99.OTHER 460. 0 1. SINGLE WALL 95. LM(NOWN 462. <br />MANUFACTURER <br />J6. DOUBLE <br />WALL 0 95. UNKNOWN <br />0 2. DOUR1.13 WALL 0 9,9. OTHER <br />MANUFAC71'URFR <br />'461, MANUFACTURER 463. <br />❑ I. RARE STEEL 0 6. FRPCOMPATIBLE W/100% %(ETHANOL 0 1. BARE S`Ithl. L3 6. FRP COMPATIBLE W/100% METHANOL <br />IJ 2. STAINLMS STEEL 0 7. 0ALVANIZED STEEL 0 2. STAINLESS STM 0 7. GALVANIZED S-IEE3, <br />n 3. PLASTIC cowAnsLE: WITH CONTENTS [195. UNKNOWN [j5.PLAS'j`!CCOMPATIBLE W/CO ENTIR 0 99. OTHER <br />NIL , 0 & FLEXIRLp <br />, (Mft) <br />APT 4. FIBERGLASS E3 a. FLEXIBLE (HDPr-,) 0 ". OTHER 0 4. FIBERGLASS 0 9. CATHODIC PROTEL'TION <br />0 5.'qTrr:l. W/COATIN40 0 9. CATHODIC PROTECTION 464 1 0 5. -STEW, W/COATINO 0 954 UNKNOWN 465. <br />VILPLIPANGL]EARDETECTI aHt=RE!y)'(Aji <br />. . 4 <br />UNDERGROUND PIPING <br />ABOVUGROUND PIPING <br />SINGLE WALL PIPING 46(- <br />SINGLE WAIL PIPING 467 <br />PR PIPING (Check all dna AV*): <br />PRNMRIZED PIPING (Check all titer apply): <br />0 1. ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST -VM. AUTO PUMP <br />SHUT-OFF FOR LEAK, SYSTEM FAILURE, AND SYSTEM DISCONNECTION <br />[] 1. EI-ECTRONICLINE LEAK DhTrCTOR 3.0 GPH TEST WITH AUTO PUMP <br />SHU'T'OFF <br />+ AUDIBLE AND VISUAL ALARMS. <br />FOR LEAK, SYSTEM FAILURE, AND SYSTEM DISCONNECTION <br />+ AUDIBLE AND VISUAL ALARMS, <br />02- MONTHLY 0.2 OPTI TEST <br />[3 z- MONTHLY 0.2 GPH TEST <br />03. ANNUAL INTEGRITY TEST (0.1 CIPH) <br />03. ANNUAL INTEGRITY TEST (0. I GPH) <br />.04. DAILY VISUAL CHECK <br />CONVENTIONAL SUCTION SV$TEMS <br />'CONVENTIONAL SUCI-10N SYSTEMS p3ca all (hat apply) <br />0 5. DAILY VISUAL moNrrokiNG OF PUMPING SYSTEM + TPUEOMAL PIPING <br />INTEGRITY TEST (0A GPH) <br />11 <br />❑5- DAILY VISUAI, MONITORING OF PIPING AND PUMPING SYSTEM <br />SAFE SUCTIONSYSTEMS(No vALvhs IN ngi.owGRouND Pipwn} <br />06. TRIENNIAL iNTEGRry-IEST(OAGPH) <br />El 7. SELPMONTrORING <br />SAFE SUCTI0.N-%VSTEMS (NO VALVES IN BELOW GROUND PJPINGp <br />GRAVTft FLCYW <br />El 7 SELF MONITORING <br />E39. EIIIENNIALINTOGRITYTEST (OAGPH) <br />GRAvrrY FLOW (check all &appzy)-. <br />0 8. DAILY VISUAL MONITORING <br />139. SilINNIAL INTEORLTY TEST (0.1 GPM) <br />SE(DONDAWLY CONTAINED Pn)'ING <br />SECONDARILY CO-VTAINED PIPING <br />PRLSSUR=D PIPING (Check all eV apply). <br />FRESSUR17XD PIPING (CiwA all djsL =Wyy. <br />10. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL <br />AND (Check o) <br />10, <br />CONTINUOUS TURBINE SJh& SE-NSOR WITH AUDIBLE AND VISUAL <br />Afaa. AUTO PUMP SHUT OFF WHEN A LEAK OCCURS <br />ALARMS AND (Check w4) <br />0 a. AUTO PUMP SHUT OFF WHEN A LEAK OCCURS <br />J91). AUTO PUMP SHUT OFF FOR LUAKS, SYSTEM FAILURE AND SYSTEM <br />0 b. AUTO PUMP SHUT OFF FOR LEAKS, SYSTEM FAILURE AND SYS11M <br />DISC-!ONNBCTION <br />11c, NO <br />DISCONNECTION <br />AUTO PUMP SHUT OFF <br />13c, NO AUTO PUMP SHUT OFF <br />C3 11. AUTO-MATICLINELEAK Dh7T7.CTOR(3.0GPH TESD WITH FLOW SHUT <br />OFF OR RESTRICTION <br />❑ I I: AUTOMATIC., i.r.A K DETECTOR <br />012. ANNUAL INTEGRITY TEST (0.1 (;pit) <br />12, ANNUAL INTEGRITY TEST (0.1 GI -H) <br />SUCnONI<;RAVrff SM&M <br />SUCTION/GRAYfrY SVSTEM <br />0 13. CONTINUOUS SUMP SENSOR + AUDIBLE AND VISUAL At -ARMS <br />EJ 13. CONIINUOUS SUMP SENSOR + AUDIBLE AND VISUAL ALARMS <br />ENIKELGENCY GENERATORS ONLY (Cheek all that apply) <br />EMERGFNCY GENERATORS ONLY (Cheek all thai apply) <br />1114- CONTINUOUS SUMP SUNSOR WITH0111 AUTO PUMP SHUT OFF <br />El 14. CONTINUOUS SUMP SENSOR Sy TROUT AUTO PUMP SHUT OFF <br />AUDIBLE AND VISUAL ALARMS <br />1315. AUTOMATIC LINE I-PAK DETECTOR (3,0 GPH TEST) Wi1'iIOUT FLOW <br />AUDIBLE AND VISUAL ALARMS <br />SHUT OFF OR RESTRICTION <br />Q. 15. AUTOMATIC LINE LEAK DETECTOR (3.0 GPH 7W - r) <br />0 16. ANNUAL INTEGRITY TrST (0.1 GIIH) <br />0 1& ANNUAL INW.GRJTY TEST (0,1 GM <br />[117. DAILY VISUAL CIIECK <br />0 17, DAILY VISUAL CHECK <br />DISPENSER CONTAINMENT' 46& 1. FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE 0 4. DALLY VISUAL CHECK 469. <br />DATE INSTALLED 0 2. CONTINUOUS DISPENSER PAN SENSOR + AUDIBLE AND VISUAL ALARMS E3 S. TRENCRUNER MONITORING <br />03. CONTINUOUS DISPENSER PAN SENSOR N_M AUTO SHUT OFF FOR <br />DISPENSER + AUDIaj.,E- AND VISUAL, ALARMS D 6. NONE <br />I Cenify that rbc information prcvzdcd here' and acmuc to the best of my knowledge. <br />SIGNATURE Or OWNER/OPERATOR <br />DATE, 470. <br />NAME OFOWNER/OPERATOR (Fiw <br />f <br />TITLE OF OWNER/OPERATOR 472. <br />Peomit Number (Agency rue tatty) 473. PWnitApproGSC. By (Aacapy - awy) a74. P -W Expo- Date (AS-cy use only) 475. <br />vir."r uwnyrL--0 tjLr") - X4 www.va5domorz Rev. 02/160 <br />eTo/ ZTO*a 000z# 60:tO 90OZ/TZ/80 <br />