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�NIFIED PROGRAM CONSOLIDATED FO I I TANK: TA0506330 <br /> PR#: PR0231261 <br /> FAC#: FA0002890 <br /> UNDERGROUND STORAGE TANKS - TANK PAGE 2 <br /> VI.PIPING CONSTRUCTION(Check all hat apply) Page 6 of 7 <br /> UNDERGROUND PIPING ABOVEGROUND PIPING <br /> SYSTEM TYPE VI.PRESSURE ❑ 2.SUCTION ❑ 3.GRAVITY 458 ❑ 1.PRESSURE ❑ 2.SUCTION ❑ 3.GRAVITY 459 <br /> CONSTRUCTION [❑L SINGLE WALL E-13.LINED TRENCH El99.OTHER 460 ❑ I.SINGLE WALL ❑ 95.UNKNOWN 462 <br /> U2.DOUBLE WALL [-195.UNKNOWN ❑ 2.DOUBLE WALL ❑ 99.OTHER <br /> MANUFACTURER 6 S,i,r`_ 461 MANUFACTURER 463 <br /> ❑ 1.BARE STEEL Lq/6.FRP COMPATIBLE W 100%METHANOL ❑ 1.BARE STEEL ❑ 6.FRP COMPATIBLE w/100°/METHANOL <br /> ❑ 2.STAINLESS STEEL ❑ 7.GALVANIZED STEEL ❑ 2.STAINLESS STEEL ❑ 7.GALVANIZED STEEL <br /> ❑ PLASTIC COMPATIBLE W/CONTENTS ❑ 95.UNKNOWN [_] PLASTIC COMPATIBLE W/CONTENTS ❑ 95.UNKNOWN <br /> ❑ 4.FIBERGLASS ❑ 8.FLEXIBLE(HDPE) ❑ 99.OTHER ❑4.FIBERGLASS ❑ 8.FLEXIBLE(HDPE) ❑ 99.OTHER <br /> ❑ 5.STEEL W/COATING ❑ 9.CATHODIC PROTECTION 464 ❑ 5.STEEL W/COATING ❑ 9.CATHODIC PROTECTION <br /> 465 <br /> VII.PIPING LEAK DETECTION(Check all that apply)(A description of the monitoring program shall be submitted to the local agency.) <br /> UNDERGROUND PIPING ABOVEGROUND PIPING <br /> SINGLE WALL PIPING 466 SINGLE WALL PIPING 467 <br /> PRESSURIZED PIPING(Check all that apply): PRESSURIZED PIPING(Check all that apply): <br /> ❑ 1.ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP SHUT OFF ❑ 1.ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP SHUT OFF <br /> FOR LEAK,SYSTEM FAILURE,AND SYSTEM DISCONNECTION+AUDIBLE AND FOR LEAK,SYSTEM FAILURE,AND SYSTEM DISCONNECTION+AUDIBLE AND <br /> VISUAL ALARMS. VISUAL ALARMS. <br /> ❑ 2.MONTHLY 0.2 GPH TEST ❑ 2.MONTHLY 0.2 GPH TEST <br /> ❑ 3.ANNUAL INTEGRITY TEST(0.1 GPH) <br /> ❑ 3.ANNUAL INTEGRITY TEST(0.1 GPH) <br /> ❑4.DAILY VISUAL CHECK <br /> CONVENTIONAL SUCTION SYSTEMS CONVENTIONAL SUCTION SYSTEMS(Check all that apply) <br /> ❑ 5.DAILY VISUAL MONITORING OF PUMPING SYSTEM+TRIENNIEAL PIPING ❑ 5.DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM <br /> INTEGRITY TEST(0.1 GPH) ❑ 6.TRIENNIAL INTEGRITY TEST(0.1 GPH) <br /> SAFE SUCTION SYSTEMS(NO VALUES IN BELOW GROUNDPIPING): SAFE SUCTION SYSTEMS(NO VALUES IN BELOW GROUNDPIPING): <br /> ❑ 7.SELF MONITORING <br /> ❑ 7.SELF MONITORING <br /> GRAVITY FLOW <br /> ❑ 9.BIENNIAL INTEGRITY TEST(0.1)GPH GRAVITY FLOW(Check all that apply): <br /> ❑ 8.DAILY VISUAL MONITORING <br /> ❑ 9.BIENNIAL INTEGRITY TEST(0.1)GPH <br /> SECONDARILY CONTAINED PIPING SECONDARILY CONTAINED PIPING <br /> PRESSURIZED PIPING(Check all that apply): PRESSURIZED PIPING(Check all that apply): <br /> 10.CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL 10.CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL <br /> ALARMS AND(Check one) ALARMS AND(Check one) <br /> ❑ a.AUTO PUMP SHUT OFF WHEN A LEAK OCCURS ❑ a.AUTO PUMP SHUT OFF WHEN A LEAK OCCURS <br /> galb.AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM ❑ b.AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM <br /> DISCONNECTION DISCONNECTION <br /> ❑ c.NO AUTO PUMP SHUT OFF ❑ c. NO AUTO PUMP SHUT OFF <br /> 11.AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)WITH FLOW SHUT OFF OR ❑ 11.AUTOMATIC LEAK DETECTOR <br /> RESTRICTION <br /> lir12.ANNUAL INTEGRITY TEST(0.1 GPH) ❑ 12.ANNUAL INTEGRITY TEST(0.1 GPH) <br /> SUCTION/GRAVITY SYSTEM SUCTION/GRAVITY SYSTEM <br /> ❑ 13.CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS ❑ 13.CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS <br /> EMERGENCY GENERATORS ONLY(Check all that apply) EMERGENCY GENERATORS ONLY(Check all that apply) <br /> ❑ 14.CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF' ❑ 14.CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF <br /> AUDIBLE AND VISUAL ALARMS AUDIBLE AND VISUAL ALARMS <br /> ❑ 15.AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)WITHOUT FLOW ❑ 15.AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)WITHOUT FLOW <br /> SHUT OFF OR RESTRICTION SHUT OFF OR RESTRICTION <br /> ❑ 16.ANNUAL INTEGRITY TEST(0.1 GPH) ❑ 16.ANNUAL INTEGRITY TEST(0.1 GPH) <br /> ❑ 17.DAILY VISUAL CHECK ❑ 17.DAILY VISUAL CHECK <br /> VIII.DISPENSER CONTAINMENT <br /> DISPENSER CONTAINMENT rIj.FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE ❑4.DAILY VISUAL CHECK <br /> DATE INSTALLED 468 ❑ 2.CONTINUOUS DISPENSER PAN SENSOR+AUDIBLE AND VISUAL ALARMS ❑ 5.TRENCH LINER/MONITORING <br /> vC 199 ❑ 3.CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR ❑ 6.NONE <br /> DISPENSER+AUDIBLE AND VISUAL ALARMS 469 <br /> IX.OWNER/OPERATOR SIGNATURE <br /> 1 cert$that the information provided herein is true and accurate to the best of my knowledge. <br /> SIGNATURE O ER/ E OR DATE 470 <br /> y, 7- <br /> NAME OF OWNS OPERATOR print) TIT E OF OWNER/OPE TOR f <br /> .fCl� n✓'= ' tn.IC S /'®k'tJ t�/c. 47t ;h<"C1✓� d %✓;/i 1 tW7sa �r �RI l" 472 <br /> Pertnit Number(For local use only) 473 Permit Approved(For local use only) 474 Permit Expiration Date(For local use only) 475 <br /> PT0002883 EE0003804 6/30/2003 <br />