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4% IINIFIFI) PROC.'RAM CONCf)1,11)ATF.t) FORM t�f TANKS UNDERGROUND STORAGE TANKS - TANK PAGE 2 Page of VI.PIPING CONSTRUC"UION(Check all that apply) -- UNDERGROUND PIPING ABOVEGROUND PIPING SYSTEM TYPE ® 1.PRESSURE ❑2,SUC9lON 0 GRAVITY 458 ❑ 1.PRESSURI': [:12 SUCTION ❑3.GRAVITY 459 CONSTRUCTION/ ❑ 1.SINGLE WALL [13.LINED TRENCH ❑99.OTHER 460 ❑ L SINGLE WALL ❑95.UNKNOWN 462 MANUFACTURER ®2.DOUBLE WALL [195.UNKNOWN ❑2.DOUBLE WALL ❑99.OTHER MANUFACTURER 461 MANUFACTURER 463 ❑ 1 BARE STEEL [16,IRP COMPATIBLE W/100%METHANOL ❑ 1 BARE STEEL ❑6 FRI'COMPATIBLE W/100%METHANOI. ❑2.STAINLESS STEEL ❑T GALVANIZED STEEL [12.STAINLESS STEEL ❑7.GALVANIZED STEEL. [13.PLASTIC COMPATIBLE WITH CONTENTS ❑95.UNKNOWN [13.PLASTIC COMPATIBLE W/CONTENTS ❑8.FLEXIBLE(HDPE-) ❑99.OTHER ®4.FIBERGLASS ❑S.FLEXIBLE(HDPE) ❑99.OTHER [14.FIBERGLASS ❑9.CATHODIC PROTECTION ❑5.STEEL W/COATING ❑9.CATHODIC PROTECTION 464 ❑5.STEEL W/COATING ❑95.UNKNOWN 465 VII.PIPING LEAK DETECTION(Check all that apply)(A description ofthe monitoring projuam shall be submitted to the local agency.) 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 ❑ L 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. ❑2. MONTHLY 0.2 GPH TEST ❑2. MONTHLY 0.2 GPH TEST ❑3. ANNUAL INTEGRITY TEST(0.1 GPH) ❑3. ANNUAL INTEGRITY TEST(0.1 GPH) ❑4. 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): ❑6. TRIENNIAL INTEGRITY TEST(0.1 GPH) ❑7. SELF MONITORING SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): GRAVITY FLOW ❑7. SELF MONITORING [19. BIENNIAL INTEGRITY TEST(0.1 GPH) GRAVITY FLOW(Check all that apply): ❑8. DAILY VISUAL MONITORING ❑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 10. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL ALARMS AND(Check one) ALARMS AND(Check one) ❑a. AUTO PUMP SI4UT OFF WHEN A LEAK OCCURS ❑a. AUTO PUMP SHUT OFF WHEN A LEAK OCCURS ®b. 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(3.0 GPH TEST)WITH FLOW SHUT ❑ 11 AUTOMATIC LEAK DETECTOR OFF OR RESTRICTION ❑12. ANNUAL INTEGRITY TEST(0.1 GPH) ❑ 12.ANNUAL INTEGRITY TEST(0.1 GPH) SUCTION/GRAVITY SYSTEM SUCTION/GRAVITY SYSTEM ❑13. CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS ❑ 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 ❑ 14.CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF AUDIBLE AND VISUAL ALARMS AUDIBLE AND VISUAL ALARMS [115. AUTOMATIC LINE LEAK DETECTOR (3.0 GPIs 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) ❑ IT DAILY VISUAL CHECK ❑ 17.DAILY VISUAL CHECK VIII.DISPENSER CONTAINMENT DISPENSER CONTAINMENT 468. ❑ 1. FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE [14. DAILY VISUAL CHECK 469. DATE INSTALLED ❑2. CONTINUOUS DISPENSER PAN SENSOR+AUDIBLE AND VISUAL ALARMS ❑5. TRENCH/LINER MONITORING 1998/11 ®3. CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR [16. NONE DISPENSER+AUDIBLE AND VISUAL ALARMS IX.OWNER/OPERATOR SIGNATURE I certify that the information provided herein is true aAd accurate to the best of my knowledge. SIGNATURE OF OWNER/OPERATODATE: I j'y�j 470 �T�41 NAME OF OWNER/OPERATOR(print. OHN S HETTER TITLE OF OWNER/OPERATOR: Environmental Consultant 472, Permit Number(Agency use only) 473. Pennit Approved By(Agency use only) 474 Permit Expiration Date(Agency use only) 475. UPCF hwfivrc-b(1/99)-3/4 http://www.unidoes.org Rev.02/16/00