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Mar -07-03 12:24P Move -fov Less 7 209 i332 8078
<br />U11111FIED 1`11011:RAM CONSOLIDATE WFORM
<br />OU US
<br />, Tol
<br />UNIDEaGROUND STORAGE TANKS- TANK PAGE 2
<br />kNDERGROUND PIPINCT
<br />"Y%Trm-rypE E12. SUCTION
<br />11�1 LNEDTRr--N('fl 0,)9. U I H E R
<br />MANUFACnMEK [3 2. DOUBLE WAI L 0 95- LNKNOWN
<br />MANUFACTURLR
<br />I. nARE STEEL 06.FRP ('O-APATIBLL W,10Q% MFTHAINM- [I I, 13A
<br />cl 2. STAINLESS STEEL 1717 GALVANIZLD STEEL 0 I:nkmwwn 0 2. S'
<br />C] 3, PLASTIC COMPATIBLE W,'CONTENTS ❑ 91) Other 0 1 PL
<br />04 4, FIBERGLASS F] 9, FI.FNIRI.r. (I lDrE) 04.1-1
<br />0 5, STEEL W,C.OATINC, [3 9. CATHODIC. PROTECTION 464 5. ST
<br />Vil. PIPING ITAK DF.TECrl0N(ovkr'Tjl,-lmJyI(
<br />-RG V rlVl-:!'
<br />S -E WALL PIPING
<br />PRESSUKIZED PIPING (C.V� kAl V.1 wly):
<br />CI I. LLECTRONIC LINE UFAK nrtTI.,(-
<br />.Tolt jrH TEST WTTII AUTO rump SHUT-
<br />OFF
<br />HUT
<br />OFF FOR J..FAK, SYSTEM FAILURE. AND SYSTEM DISCONNECTION
<br />AUDIBLE AND VISUAI. ALARMS.
<br />0 1. MONTIII-Y 0.2 GPH TE!;I-
<br />10 3ANN-IIAL INTEUKITY TEST (0 1r.P11)
<br />CONVENTIONAL SUCTION SYSIEM-"
<br />E] S. DAILY VISUAL MON[TO)UNG OF PUMPINCS-Y511161 "CRIF."TALPIPING
<br />INTEuRI-1-Y TEST (0 1 c-mul)
<br />SAFE* SUCrlON SYSTEMS (NOV ALIJES IN ULLOW GROLINDPIPINO):
<br />7. SELF MON 17 ORIN(j,
<br />GRAVITY FLOW
<br />[];). BIENNIAL INTr..(-.RiT)* i -Ls I- Io, I (jell)
<br />scr.ONDARILY CO.', fAINFI) PIPING
<br />pl,ESSURUT-1) PIPING Wh&R all,11A amb-1:
<br />10. CONI'INI-7LIUS TL*RRINF SUMP ALrill"ll.F. AND VISUAL
<br />ALARMS AND fChtck uncl
<br />[]a. AUTO PUMI'SIIL-1'0FF WHEN A Lr.AK OCCURS
<br />0 b. AUTO PI IMP SHUT OFT FOR LEAKS. SYSTrM FAILURE ANL) SYSTEM
<br />DISCUNNECTION
<br />®c. NO AUTO PUMP SHUT OFF
<br />I I. AUTOMATIC 1JNF i.r-AK uwi:`TEc'l'ox. (1.0 GPH TEST) wil-H FLOW SHUT
<br />orr OR KESTKI(:l ION
<br />D IT ANNI)AT. INTi.*.(;Rj,ry TEs r f0.1 OPI 1)
<br />St;L-.TI()V/(-,RAVrTY SYSTEM(3. C.()NTINIJ(-§I.SSUMP SLNSOK + AL)DIRI.F AND VISUAL ALAFLMS
<br />F.%IFR(;ENCY GEpwEjwIjATOR5 ONLY Y:ftKk 91 Iful WIV
<br />14. CONTINLOUS SUMP ST-,N%()R W-ITHOUT AUTO PUMP SlRJT OFF
<br />AUDIBLE ANi)VISIIAL ALARMS
<br />C]15, AIJTOMATI(.'[.INELEAK DETECTnR(1.0(;PIITLS'['))MIIHOLI FI -OW
<br />SHUT OFF OR RKSTR I(.-r1ON
<br />❑ 16. ANNUAL jNTr(;RITY TES r (U.1 GPH)
<br />❑ 17. DAILY VISUALCIM.'CV,
<br />DISPENSEKcoN'rAr,-'mFNT
<br />DATE INSTALLED A&3
<br />Iliff
<br />i."tiry
<br />01 dW 1 1, -
<br />pike of
<br />-11. -
<br />ADOVEGROL;ND PIPING
<br />aca 0 1. GRAVITY .139
<br />D WALL
<br />0 95, UNKNOWN 462
<br />02.DOUF4j.F.WAI.L
<br />oy,)-orHER
<br />MANUFACTURrIZ
<br />F,E SfEEL
<br />6. FRF COMPATIRIT, Wflmr4 NIP'7HAN01.
<br />,UNLESS STEEL
<br />0 7. GALV&VIZEn STFFI.
<br />ASTICCL)MPAfIRLF W,'f.ON-TENT.S
<br />CI U, FLEXIBLE (HDPE) [:]99 O'n 1 F. R
<br />ULRULASS
<br />1). CATHODIC PR(:)TE(7.TIC-
<br />EF.I. W/COATING
<br />95. UNKNOWN 441
<br />"emmon of the mmixoring ptomm
<br />Vill. DISPENSER
<br />1. FLOATmECHANIqxf TI IAT SHUTS UFF SSMEAR VALVE
<br />cl 2, CONTINUOUS L)ISPI:,NSr-.R PAN SENSOR AUDIBLE AND V151 IA 1. ALARMS
<br />❑ 3 CONTINUOUS DISPENSER PAN Sr-14SOR WITH ALTO SHUT' OFF FOR
<br />DISI-ENSF.g - AUDIBLE AND VISUAL ALARMS
<br />Ix. OWNERiOPEIZATOR SIGNATU Rk,
<br />5ENGLE WAVY, PIPINr aar
<br />pRE--O9IZrD PiPr,,(; (check an that applyl,
<br />[31 FIRCTRONIC LINE LEAK DETECTOR 3 ti
<br />(3PIlTr-1qTWITIIAUTO PUMP
<br />stiLT OFF VOk LEAK,.SYITr.M FAILURE, AND SYSTEM DISCONNECTION
<br />AVDIRLE AND VISUAL ALARMS.
<br />Mopi'l HI,Y 0 2 GPI4 TEST
<br />0 J. ANNUAL FNTFCRITY TEST (1). IGPII)
<br />04, (IAIIYVfSI1AI.CIIFCK
<br />CONVENTIONAL SI.1(7TION SYSTEMS (check all that VOW
<br />El S. DAILY YISUALmONITORINO OF PIPING AND PUTAPINU SY,'I*EM
<br />®Z 'TRUE°�NtA1.InircIRITYTCs'1'to.itiPH)
<br />SAFE SC0 ION'SYSTF.MS (NO VALVES IN HELOT/ OKOUND PIPING)-
<br />[:17. SELF MONI I OPJNG
<br />GRAVITY FLOW (('hcck:lf!Uapply):
<br />R. DAILY VISUAL Mutml-OKING
<br />9. n'FNNIAL INTEURfIXTEST (0.1 GP;I)
<br />SECOr4t),kR11,V r.ON'TAINED PIPIN(;
<br />PRLSSURIzu) J'lrl%'c; tch"k $11 9.1apply)
<br />10. CONTINUOUS TURBINE SUMP SENSOR AITII AUDInf.r.. AND VISUAL
<br />ALAJL14S AND
<br />n , AU 10 rUMe SHUT OFF Wl IrN A LFAK O(:CUKS
<br />b AUTO PLMI'SHUT' OFF FOR I,FAK-5, qV.1TEM I'AILURI: AND SYSTEM
<br />D)S('riNNr-.MON
<br />0, N0AUTO PUMP .qinjTOFF
<br />0 11. AUTOMATIC LEAK
<br />0 12, ANNUAL IN'fEGPJTY TFST (0. 1 GP11)
<br />sucTioNtUKAVI'l Y SYSTEM
<br />0 13. CON,I*LNUOLS SUMP SENSOR - AUDIRI-1- AND VISUAL ALARMS
<br />E,vLEKGE'4CV ONLY tcheck all that 30PIV)
<br />[3 14. CONTI\I.TOII.'q SUMP SI;NSOK W11 HOLIT AUTO PUMP SHUT OFF
<br />AUDIBLE AND VISUAL ALARMS
<br />0 15. AUTOMAr(C LINE LE -AK nr.TF-.r.TnR (3.0 (;PII TEST)
<br />F1 16. ANNUAL INI EGRJ'I YTEST (f) I 10P11)
<br />C1 17. DAILY VISUAL CHECK
<br />"Wb�rulw-,N-EkopP AT4)R(pirinl)
<br />7'b4'''Vz
<br />F;;;a -r4umber I rut kycai um Only)
<br />UPCF (12199 revised)
<br />=I
<br />M
<br />91
<br />Q4. DAILY VISUAL CHECK
<br />5. TRENCH LINER. i MONITORING
<br />6. NONL 469
<br />--ly) 4115
<br />
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