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LqWD PROGRAM CONSOLIDATED FO9W TANKS UNDERGROUND STORAGE TANKS - TANK PAGE 2 P age of UNDERGROUND PIPING ABOVEGROUND PIPING SYSTEM TYPE 1.PRESSURE ❑2.SUCTION [13.GRAVITY 458. [11.PRESSURE 0 2.SUCTION 0 3.GRAVITY 459. CONSTRUCTION/ ❑ 1.SINGLE WALL ❑3.LINED TRENCH 0 99.OTHER 460. 0 1.SINGLE WALL [195.UNKNOWN 462. MANUFACTURER 2.DOUBLE WALL ❑95.UNKNOWN [12.DOUBLE WALL 0 99.OTHER MANUFACTURER Smith Fibercast 461 MANUFACTURER 463, ❑ 1.BARE STEEL 6.FRP COMPATIBLE W/100%METHANOL ❑1.BARE STEEL [16.FRP COMPATIBLE W/100%METHANOL ❑2.STAINLESS STEEL ❑7.GALVANIZED STEEL ❑2.STAINLESS STEEL D 7.GALVANIZED STEEL ❑3.PLASTIC COMPATIBLE WITH CONTENTS 0 95.UNKNOWN [3 3.PLASTIC COMPATIBLE W/CONTENTS [18,FLEXIBLE(HDPE) ❑99.OTHER ❑4.FIBERGLASS ❑8.FLEXIBLE(HDPE) [199.OTHER ❑4.FIBERGLASS D 9.CATHODIC PROTECTION ❑5.STEEL W/COATING ❑9.CATHODIC PROTECTION 464. ❑5.STEEL W/COATING ❑95.UNKNOWN 465. k';A4*riPtiP'ft oithe,midnjo ge,40y) UNDERGROUND PIPING ABOVEGROUND PIPING SINGLE WALL PIPING 466. SINGLE WALL PIPING 467. PRESSURIZED PIPING(Check all that apply): PRESSURIZED PIPING(Check all that apply): 0 1. ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP [11. ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP SHUT-OFF FOR LEAK,SYSTEM FAILURE,AND SYSTEM DISCONNECTION SHUT OFF FOR LEAK,SYSTEM FAILURE,AND SYSTEM DISCONNECTION +AUDIBLE AND VISUAL ALARMS. +AUDIBLE AND VISUAL ALARMS. 0 2. MONTHLY 0.2 GPH TEST 02. MONTHLY 0.2 GPH TEST [13. ANNUAL INTEGRITY TEST(0.1 GPH) [13. ANNUAL INTEGRITY TEST(0.1 GPH) [14. DAILY VISUAL CHECK CONVENTIONAL SUCTION SYSTEMS CONVENTIONAL SUCTION SYSTEMS(Check all that apply) ❑5. DAILY VISUAL MONITORING OF PUMPING SYSTEM+TRIENNIAL PIPING [15. DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM INTEGRITY TEST(0.1 GPH) SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): [16. TRIENNIAL INTEGRITY TEST(0.1 GPH) 0 7. SELF MONITORING SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): GRAVITY FLOW [17. SELF MONITORING 09. BIENNIAL INTEGRITY TEST(0.1 GPH) GRAVITY FLOW(Check all that apply): [18. 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 10. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL ALARMS AND(Check one) ALARMS AND(Check one) a. AUTO PUNT SHUT OFF WHEN A LEAK OCCURS 0 a. AUTO PUMP SHUT OFF WHEN A LEAK OCCURS b. AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM [I b.AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM DISCONNECTION DISCONNECTION [3c. NO AUTO PUMP SHUT OFF [3c. NO AUTO PUM]?SHUT OFF 011. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)WITH FLOW SHUT ❑11. AUTOMATIC LEAK DETECTOR OFF OR RESTRICTION 012. ANNUAL INTEGRITY TEST(0.1 GPH) ❑12. ANNUAL INTEGRITY TEST(0.1 GPH) SUCTION/GRAVITY SYSTEM SUCTION/GRAVITY SYSTEM [113. CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS [113, CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS EMERGENCY GENERATORS ONLY(Check all that apply) EMERGENCY GENERATORS ONLY(Check all that apply) 014. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF ❑14. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF AUDIBLE AND VISUAL ALARMS AUDIBLE AND VISUAL ALARMS 015. AUTOMATIC LINE LEAK DETECTOR (3.0 GPH TEST) WITHOUT FLOW ❑ 15. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST) SHUT OFF OR RESTRICTION [116. ANNUAL INTEGRITY TEST(0.1 GPH) ❑16. ANNUAL INTEGRITY TEST(0.1 GPH) Cj 17. DAILY VISUAL CHECK D 17. DAILY VISUAL CHECK VIU:DISI' SERI CONTAINNO" DISPENSER CONTAINMENT 468. ❑1. FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE ❑4. DAILY VISUAL CHECK 469. DATE INSTALLED 0 2. CONTINUOUS DISPENSER PAN SENSOR+AUDIBLE AND VISUAL ALARMS 05. TRENCH/LINER MONITORING 2005 0 3. CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR 06. NONE DISPENSER+AUDIBLE AND VISUAL ALARMS I certify that the information pr vide to the best of my knowledge. SIGNATURE OF OWNER/O 0_�Oereinjs true and ac DATE: 4/18/05 470, NAME OF OWNER/OPERATOR(print): Michael E.Walton TITLE OF OWNER/OPERATOR: Contractor 472. Permit Number(Agency use only) 473. 1 Permit Approved By(Agency use only) 474. 1 Permit Expiration Date(Agency use only) 475. UPCF hwfwre-b(1/99)-3/4 http://www.unidoes.org Rev.02/16/00