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WNIFIED PROGRAM CONSOLIDATED FOR* (f"' I ' /_� " <br /> TANK: TA0506329 <br /> PR#: PRO231261 <br /> 3 U FAC#: FA0002890 <br /> UNDERGROUND STORAGE TANKS - TANK PAGE 2 <br /> VI.PIPING CONSTRUCTION(Check a0 fiat apply) Page 3 of 7 <br /> UNDERGROUND PIPING ABOVEGROUND PIPING <br /> SYSTEM TYPE ['1.PRESSURE ❑ 2.SUCTION ❑ 3.GRAVITY 458 ❑ 1.PRESSURE ❑ 2.SUCTION ❑ 3.GRAVITY 459 <br /> CONSTRUCTION ❑1.SINGLE WALL ❑3.LINED TRENCH ❑ 99.OTHER 460 ❑ 1.SINGLE WALL ❑ 95.UNKNOWN 462 <br /> �2.DOUBLE WALL ❑95.UNKNOWN ❑ 2.DOUBLE WALL ❑ 99.OTHER <br /> MANUFACTURER 4 6 S.,,'h- 461 MANUFACTURER 463 <br /> ❑ 1.BARE STEEL g3"6.FRP COMPATIBLE w/I00%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 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 ❑ 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 <br /> 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 /> ❑b.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 /> ❑ 12.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 1.FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE ❑4.DAILY VISUAL CHECK <br /> DATE INSTALLED <br /> 469 ❑ 2.CONTINUOUS DISPENSER PAN SENSOR+AUDIBLE AND VISUAL ALARMS ❑ 5.TRENCH LINER/MONITORING <br /> UC-40,t A j,_ /c/76 7 6 El3.CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR ❑ 6.NONE <br /> / DISPENSER+AUDIBLE AND VISUAL ALARMS 469 <br /> IX.OWNER/OPERATOR SIGNATURE <br /> I certify that the information provided herein is true and accurate to the best of my ktu x lodge. <br /> S I G N An F E RpPE I jhOR DATE 470 <br /> 7 Z'y - c1L <br /> NAME OF OWNE OPERAT/OR(rint) _ TITL OF OWNOPERAT <br /> i��P' 92✓L:LCl ,C u.�< S�G' /�//G7`J; .1�ITG. a71 tl� 472 <br /> Permit Number(Fm 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 />