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UNIFIED PROGRAM CONSOLIDATED FORM <br />TANKS <br />UNDERGROUND STORAGE 'TANKS - TANK PAGE7 <br />ER C of <br />UNDERGROUND PIPING <br />ABOVEGROUND PIPING <br />SYSTE 4 TYPE I. PRESSURT,, E3 2. SUCTION Q 3. GRAVITY 456. Jffj.PRESSURE 02.SUCTION 01 GRAVITY 459. <br />-0 <br />CONSTRUCMN/ i.SINGLEWALL El 3, LINED TRENCIT 99. OTHER 460 <br />MANUFACFURZR 0 1. SINGLE WALL L3 95. UNKNOWN 462 <br />.Z2. DOUBIX WALL 0 95. UNKNOWN, <br />0 2, DOUBLE WALL 0 99. OTHER <br />MANUFACTURER <br />46t.v� <br />I MANUFAMIRER 463. <br />01. BARE STEEL 0 6. FRP COMPATIBLE W/100%.MMIANOL 0 I. BARE STEM 13 6. RP COMPATIBLE W/100% METHANOL <br />El 2. STAINLESS STEEL 0 7. GALVAN17M STEEL E3 2, STAINLESS STEEL Q 7. GALVAN17M STEEL <br />El 3. PLAS11C COMPATIBLE WITH CONTENTS 13 95. UNKNOWN [3 3. PLASTIC COMPATIBLE w/ CONTENTS [3 8. FLEXIBLE (I -WE) 0 99. OrITIER <br />A4-FIBRWAIASS 13 S. FLEXIBLE (HDPE) C) 99. OTHER EJ 4. F1UERGLA-53 El 9. CATHODIC PROTECTION <br />05. STEEL WICOATING [39.CATW)DtCPROTECTION S. STEEL W/COXIING 0 95. UNKNOWN 40. <br />VIS. PIPARG LEAK DETECnoN <br />UNDERGROUND PIPING <br />ABOVEGROUND PIPING <br />MNGLF WALL PIPING 466. <br />SI WALL PIPING 467. <br />PRESSURM11 PIPING (Check all that applyy <br />. PRMUR=D PIPING (Chock all tbw apply): <br />0 1. ELFCTRONIC LINE LEAK DETECTOR 3.0 GM TOT V= AUTO PUMP <br />01. ELECTRONIC I.TNELEAK DFTECT0R3.0(*MITFST-v=AUTO PumP <br />SHUT-OFF FOR LEAK, SYSTEM FAILURE, AND SYSTIZM DISCONNECTION <br />SHW'OrP FOR LEAK, SYSTEM FAILURE, AND SYS'I'EM DISCONNECrION <br />4 AUDIBLE AND VISUAL ALARMS. <br />4 AUDIBLE AND VISUAL ALARMS. <br />13 2. MONTHLY 0.2 GPH TEST <br />[32. MONTHLY 0.2 GPH TFtsT <br />03. ANNUAL INTEGRITY TEST (0.1 GIB)' <br />0 i ANNUAL INTEGRITY Tw(o.i opu) <br />C! 4. DAILY VISUAL CHECK <br />CONVENTIONAL SUCTION SYSTEMS <br />CONVENTIONAL SUCTION SYSTEMS (Cheek an that apply) <br />05. DAILY VISUAL MONITORING OF FUMIqNG SYS rrM+TRESNNIAL PIPING <br />INTEGRITY TEST (0.1 GPH) <br />rl 5. DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM <br />SAFE SUCTION SYSTEMS (NO VALVES IN BELOW GROUND PFPMGY <br />06. TRIENNIAL INTEGRITY TEST (0.1 GM <br />[17. SELFM07111TORING <br />SAFE SUCTION SYSTEMS (NO VA-LVES IN BELOW OROUND PFMG): <br />GRAVITYFLOW <br />0 7. SELF MONITORING <br />09. BIENNIAL INTEGRITY TEST (0.1 am) <br />GRAVITY FLOW (Check all that apply): <br />09. DAILY VISUAL MONITORING <br />0 9. RMIINLAL INTR.GRITY 'MST (0,1 GPH) <br />SECONDARILY CONTAINFI) PIPING <br />SECONDARILY CONTAINED PIPING <br />PRILSSURIZED PIPING (Cheek ail that apply): <br />P110"URMED PIPING (Check all that apply): <br />10. CONTINUOUS TURBINE SUMP SENSOR WrM AUDIBLE AND VISUAL <br />10. CONTINUOUS TURBINE SUMP SENSOR WITII AUDIBLE AND VISUAL <br />ALARM AND (Check one) <br />ALARMS AND (Chock one) <br />,ffa. AUTO PUMP SHUT OFF WHEN A LEAK OCCURS <br />El a. AUTO PUMP SHUT orr WREN A LEAK 0CL7URS <br />,Wt- AUTO KR& SHUT OFF FOR LEAKS, SYSTEM FAILURE AND SYSTEM <br />0 b. AUTO PUMP SHUT OFF FOR LEAKS, SYSTEM FAILURE AND SYSTEM <br />DISCONNECTION <br />DISCONNECTION <br />[3c. NO AUTO PUMP SHUT OFF <br />0c. NO AUTO PUMP SHUT OFF <br />1. AUTOMATIC LINE LEAK DETECTOP (3.0 OPH TEST) WITH FLOW SHUT <br />OFF ()R RESTRICTION <br />®t I. AUTOMATIC LEAK DL11DCTOR <br />Q 12. ANNUAL fNTEGKrTY TEST (0,1 GM <br />0 11 'ANNUAL INTEGRITY TEST (0.1 GM) <br />SUCTIONIGRAVITY SYSTEM <br />SUCTJOMGRAVITY SYSTEM <br />M. CONTINUOUS SUMP SENSOR + AUDIBLE AND VISUAL ALARMS <br />0 13. CONTINUOUS SUMP SENSOR + AUDiaLrz AND VISUAL ALARMS <br />EMERGMY GENERATORS ONLY (Chock all that apply) <br />EMERGENCY GENERATORS ONLY (Check all that uppiy) <br />C3 u. CONTINUOUS SUMP SENSOR -WMIM AUTO PUMP SHUT OFF <br />1114. CONTINUOUS S" SENSOR -wD.ao_uT Aurc) Pump SHUT OFF <br />AUDIBLE AND VISUAL ALARMS, , <br />AUDIBLE AND VISUAL ALARMS <br />AUTOMATIC LINE I.CAK DETECTOR (3.0 GPH TEST) W�-r FLOW <br />SHUT OFF OR RESTRIC11ON <br />❑ <br />0 15. AUTOMATIC LINE LF AK DETECTOR (3.0 rPII TEST) <br />"56. ANNUAL INTEGRITY TOT (0.1 GPH) <br />ow I <br />Q 16, ANNUAL INTEC' 3RITY TEST (0.1 GPH) <br />L3 17. DAILY VISUAL CHECK <br />0 17. DAILY VISUAL CHECK <br />WACONTAMMENT <br />DISPONSERCONTAD04ENT 468. <br />. FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE [14. DAILY VISUAL CHECK 469. <br />DATE INSTALLED <br />El 2 CONTINUOUS DiSmNSERPAN SENSOR+AUDIBLE AND VISUAL ALARMS E3 5. TRENCH41M MONITORING <br />[3 3. CONTINUOUS DISPENSER PAN SENSOR Yn2j AUTO SHUT OFF FOR <br />06. NONE <br />DISPENSER + AUDIBLE AND VISUAI, <br />ALARMS <br />DL OWNERIOPERiVrOWSIGNATURE <br />I certify that the iaf rovi&d herein is true and s=rate to the best ofnr <br />y knowledge - <br />SIGNATURE OF <br />DATE: 470. <br />NAMP OF OWN0WPERATORWw).- <br />1.1 xlepllvoexl f-PlIzw <br />TITLE OF OWNEMPERATOR. 472. <br />1 P==it Nmubcr (Agency ON ady) 473. 1 P -mit Apprw4od By (Aponoy - only)777` t Expiration Due (Aacricy use o*) 47.5. <br />UPCF hwfwm-b (V") - 3/4 www.uaidocs.org Rev. 0zq6w <br />810/ WTO'd OOOZ# 0T w0 9002/Tz/e0 <br />