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UNIFIED PROGRAM CONSOLIDATED FORM TANKS UNDERGROUND STORAGE TANKS -TANK PAGE 2 Pape-,-, UNDERGROUND IPIN ABOVEGROUND PIPING SYSTEM TYPE1 PRESSURE r 2. SUCTION r 3. GRAVITY r 1. PRESSURE r 2. SUCTION r 3. GRAVITY 459 CONSTRUCTION/ r 1. SINGLE WALL IF 3. LINED TRENCH I'99. OTHER r 1. SINGLE WALL r95, UNKNOWN 462 MANUFACTURE - DOUBLE WALL 1-95. UNKNOWN I'2. DOUBLE WALL r 99. OTHER R �-6�� MANUFACTURER � �r 461 MANUFACTURER 463 r 1.BARE STEEL r 6. FRP COMPATIBLE VIM 100%METHANOL r 1. BARE STEEL r 6. FRP COMPATIBLE W0100%METHANOL MATERIALS AND r 2. STAINLESS STEEL r 7. GALVANIZED STEEL r 2. STAINLESS STEEL r 7. GALVANIZED STEEL CORROSION PROTECTION r 3 PLASTIC COMPATIBLE WITH CONTENTS F95. UNKNOWN r 3. PLASTIC COMPATIBLE WITH CONTENTS r 8. FLEXIBLE(HDPE) 1'99. OTHER 4. FIBERGLASS IF 8. FLEXIBLE(HDPE) r99. OTHER r 4. FIBERGLASS IF 9. CATHODIC PROTECTION r 5. STEEL w COATING r 9 CATHODIC PROTECTION 464 1r S STEEL VV COATING r 95 UNKNOWN 465 a.:.' A, Y:s s ."»ssssy us;ra�;� a �.uk. °w...'�➢fss"��«3n�`. ,i.��,,.1 ?>i'a s n �,.M. �i i r' .'i!?" �z, '� $3* �z. �IPIPIN F_ ECT �3D/t( " desCrip�3rrfthemrmtonnStPm9rlishatlsu6mi(tesUUtoth4tque'agencF UNDERGROUND PIPING ABOVEGROUND PIPING SINGLE WALL PIPING 466 SINGLE WALL PIPING 467 PRESSURIZED PIPING(Check all that apply): PRESSURIZED PIPING(Check all that apply): r 1. ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP SHUT OFF FOR r 1. ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP SHUT OFF FOR LEAK LEAK SYSTEM FAILURE,AND SYSTEM DISCONNECTION+AUDIBLE AND VISUAL SYSTEM FAILURE,AND SYSTEM DISCONNECTION---AUDIBLE AND VISUAL ALARMS ALARMS r 2. MONTHLY 0.2 GPH TEST r 2. MONTHLY 0.2 GPH TEST r 3. ANNUAL INTEGRITY TEST(0.1 GPH) IF 3. ANNUAL INTEGRITY TEST(0.1 GPH) IF 4. DAILY VISUAL CHECK CONVENTIONAL SUCTION SYSTEMS: CONVENTIONAL SUCTION SYSTEMS(Check all that apply): r 5. DAILY VISUAL MONITORING OF PUMPING SYSTEM+TRIENNIAL PIPING INTEGRITY r 5. DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM TEST(0.1 GPH) r 6. TRIENNIAL INTEGRITY TEST(0.1 GPH) SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): r 7. SELF MONITORING r 7. SELF MONITORING GRAVITY FLOW. GRAVITY FLOW(Check all that apply): r 9. B IENNL4L INTEGRITY TEST(0.1 GPH) IF 8. DAILY VISUAL MONITORING r 9. 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) XAUTO PUMP SHUT OFF WHEN A LEAK OCCURS r a AUTO PUMP SHUT OFF WHEN A LEAK OCCURS AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM DISCONNECTION r b. AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM DISCONNECTION r c. NO AUTO PUMP SHUT OFF r G NO AUTO PUMP SHUT OFF 11. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)WITH FLOW SHUT OFF OR IF 11. AUTOMATIC LEAK DETECTOR RESTRICTION IF 12. ANNUAL INTEGRITY TEST(0.1 GPH) r 12. ANNUAL INTEGRITY TEST(0.1 GPH) SUCTIONGRAVITY SYSTEM: SUCTION/GRAVITY SYSTEM: r 13. CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS r 13. CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS EMERGENCY GENERATORS ONLY(Check all that apply) EMERGENCY GENERATORS ONLY(Check all that apply) F 14. CONTINUOUS SUMP SENSOR WTTHOUTAUTO PUMP SHUT OFF+AUDIBLE AND r 14. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF+AUDIBLE AND VISUAL VISUAL ALARMS ALARMS r 15. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)WITHOUT FLOW SHUT OFF OR I' 15. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST) RESTRICTION r 16. ANNUAL INTEGRITY TEST(0.1 GPH) r 16. ANNUAL INTEGRITY TEST(0.1 GPH) rIT DAILY VISUAL CHECK r 17. DAILY VISUAL CHECK q $i vrl$ rs ENs�R CbN AI M N - s �x ;. , ,m`e ff , .dam.:,r,, *. DISPENSER CONTAINMENT r 1. FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE r 4. DAILY VISUAL CHECK DATE INSTALLED 468_Y� CONTINUOUS DISPENSER PAN SENSOR+AUDIBLE AND VISUAL ALARMS r 5. TRENCH LINER/MONITORING r 3. CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR DISPENSER+AUDIBLE AND VISUAL ALARMS r 6. NONE 469 1X O,INNER(OPERATOR 51GNAtURE. I certify that the information provided herein is true and accurate to the best of my knowledge. SIGNAT F OWN OPEIQR DATE 470 NAME OF OWNER/OPERATOR(print) 471 TITL OF OWNEP4bPERATbR 472 Permit Number(For local use only) 473 1 Permit App (For local use only) 474 Permit Expiration Date(For local use only) 475