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UNIFIED PROGRAM CONSOLIDATED FORIW TANK UNDERGROUND STORAGE TANKS - TANK PAGE 2 STI APING CONST ly? Page_of UNDERGROUND PIPING ABOVEGROUND PIPING SYSTEM TYPE N 1.PRESSURE ❑2.SUCTION ❑3.GRAVITY 458 ❑1.PRESSURE ❑2. SUCTION ❑3.GRAVITY 459 CONSTRUCTION, ❑1.SINGLE WALL ❑3.LINED TRENCH ❑99.OTHER 460 ❑1.SINGLE WALL ❑95.UNKNOWN 462 MANUFACTURER N 2.DOUBLE WALL [:195.UNKNOWN ❑2.DOUBLE WALL ❑99.OTHER MANUFACTURER 461 MANUFACTURER 463 ❑1.BARE STEEL ❑6.FRP COMPATIBLE w1100i METHANOL ❑1.BARE STEEL ❑6.FRP COMPATIBLE w/lmmErHANOL ❑2.STAINLESS STEEL ❑7.GALVANIZED STEEL ❑UKNOWN ❑2 STAINLESS STEEL ❑7.GALVANIZED STEEL ❑3.PLASTIC COMPATIBLE WI CONTENTS [:199. OTHER ❑3. PLASTIC COMPATIBLE W/CONTENTS ❑8.FLEXIBLE(HDPE) ❑99. OTHER ®4.FIBERGLASS ❑8.FLEXIBLE(HDPE) ❑4. FIBERGLASS ❑9.CATHODIC PROTECTION ❑5.STEEL W/COATING ❑9.CATHODIC PROTECTION 464 ❑5. STEEL W/COATING ❑95.UNKNOWN 465 VII.PIPING LEAK DETECT.ION(Checicallthat apply),(Ad@scrtptrcSt,oCttte,plYitcrrangpcogram;'shaltbesnbFlt,!Uigthslocalagepcy); °r ." UNDERGROUND PIPING ABOVEGROUND PIPING SINGLE WALL PIPING 466 SINGLE WALL PIPING 467 PRESSURIZED PIPING(Check all that apply) PRESSURIZED PIPING(Check all that apply): ❑1 ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP SHUT OFF FOR ❑1. ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP SHUT OFF FOR LEAK,SYSTEM FAILURE.AND SYSTEM DISCONNECTION+AUDIBLE AND VISUAL LEAK,SYSTEM FAILURE,AND SYSTEM DISCONNECTION+AUDIBLE AND VISUAL ALARMS ' ALARMS. ❑2. MONTHLY 0.2 GPH TEST ❑2. MONTHLY 0.2 GPH TEST ❑3. ANNUAL INTEGRITY TEST(0.1GPH) ❑3. ANNUAL INTEGRITY TEST(0.1GPH) ❑4. DAILY VISUAL CHECK CONVENTIONACSUCTION SYSTEMS CONVENTIONAL SUCTION SYSTEMS(Check all that apply) E15. DAILY VISUAL MONITORING OF PUMPING SYSTEM-TRIENNIAL PIPING INTEGRITY ❑5. DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM TEST(0.1 GPH) j SAFE SUCTION SYSTEMS(NO VALUES IN BELOW GROUNDPIPING): ❑6. TRIENNIAL INTEGRITY TEST(0.1 GPH) ❑7. SELF MONITORING SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): GRAVITY FLOW ❑7. SELF MONITORING ❑9. BIENNIAL INTEGRITY TEST(0.1 GPH) GRAVITY FLOW(Check all that apply): ❑8. DAILY VISUAL MONITORING [19. BIENNIAL INTEGRITY TEST(0.1 GPH) SECONDARILY CONTAINED PIPING SECONDARILY CONTAINED PIPING PRESSURIZED PIPING(Check all that apply) PRESSURIZED PIPING(Check all that apply): 10. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL ALARMS AND 10. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL ALARMS AND (Check one) (Check one) ❑a. AUTO PUMP SHUT OFF WHEN A LEAK OCCURS ❑a AUTO PUMP SHUT OFF WHEN A LEAK OCCURS Nb, AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM ❑b AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM DISCONNECTION DISCONNECTION ❑c. NO AUTO PUMP SHUT OFF ❑c NO AUTO PUMP SHUT OFF ❑11. AUTOMATIC LINE LEAK DETECTOR 13.0 GPH TEST)WITH FLOW SHUTOFF OR ❑11. AUTOMATIC LEAK DETECTOR RESTRICTION ❑12. ANNUAL INTEGRITY TEST(0.1 GPH) ❑12. ANNUAL INTEGRITY TEST(0.1 GPH) SUCTION/GRAVITY SYSTEM SUCTION/GRAVITY SYSTEM 013. CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS C1 13. CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS EMERGENCY GENERATORS ONLY(Check all that apply) EMERGENCY GENERATORS ONLY(Check all that apply) ❑14. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF+AUDIBLE AND ❑14. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF+AUDIBLE AND VISUAL ALARMS VISUAL ALARMS ❑15. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)WITHOUT FLOW SHUT OFF OR ❑15. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST) RESTRICTION ❑16. ANNUAL INTEGRITY TEST(0.1 GPH) ❑16. ANNUAL INTEGRITY TEST(0.1 GPH) ❑17. DAILY VISUAL CHECK ❑17. DAILY VISUAL CHECK VIII.DISPENSER'', DISPENSER ❑1. FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE ❑4.DAILY VISUAL CHECK CONTAINMENT DATE INSTALLED 468 ❑2. CONTINUOUS DISPENSER PAN SENSOR+AUDIBLE AND VISUAL ALARMS ❑5.TRENCH LINER/MONITORING 03. CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR DISPENSER+ ❑6.NONE 469 AUDIBLE AND VISUAL ALARMS IXOWNER/OPERATOIS( w/TUFLE s_ K o ,�r r." .. rl certify that the ante anon orovi e herein is true and accurate to the best of my knowledge. SIGNATU C OVVNE BATOR DATE 470 12/3/01 NAME OWNER/OPRATOR;print) TITLE OF OWNER/OPERATOR 472 Jac hcades Director of Engineering Permit umber-.r-cr-.oca,❑se only, 473 Permit Approved(For local use only) Permit Expiration Date(For local use only) 475