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IFUD PROGRAM CONSOLmATED TANKS UNDERGROUND STORAGE TANKS - TANK PA 2 Page of VL PIPING CONSTRUCTION (check au that UNDERGROUND PIPING ABOVEGROUND PIPING SYSTEM TYPE Q L PRESSURE [12- SUCTION ❑ 3. GRAVITY 458. ❑ 1. PRESSURE ❑ 2. SUCTION ❑ 3. GRAVITY 459. CONSTRUCTION/ ❑ L SINGLE WALL ❑ 3. LINED TRENCH ❑ 99. OTHER 460. ❑ 1. SINGLE WALL ❑ 95. UNKNOWN 462. MANUFACTURER ® 2. DOUBLE WALL ❑ 95. UNKNOWN [12. DOUBLE WALL ❑ 99. OTHER MANUFACTURERU 'y s 461. MANUFACTURER 463. . ❑ 1. BARE STEEL ❑ 6. FRP COMPATIBLE W/ 100% METHANOL ❑ 1. BARE STEEL ❑ 6. FRP COMPATIBLE W/100°/ METHANOL ❑ 2. STAINLESS STEEL ❑ 7. GALVANIZED STEEL [12- STAINLESS STEEL ❑ 7. GALVANIZED STEEL ❑ 3. PLASTIC COMPATIBLE WITH CONTENTS ❑ 95. UNKNOWN ❑ 3. PLASTIC COMPATIBLE W/ CONTENTS ❑ 8. FLEXIBLE (HDPE) ❑ 99. OTHER A 4. FIBERGLASS ❑ 8. FLE)aBLE (HDPE) ❑ 99. OTHER ❑ 4. FIBERGLASS ❑ 9. CATHODIC PROTECTION ❑ 5. STEEL W/COATING ❑ 9. CATHODIC PROTECTION 464- ❑ 5. STEEL W/COATING [195 UNKNOWN 465. VM PIPING LEAK DETECTION (Check all tint ) (A -am of the nxmAon g program shall be submitted to the Local .) 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 WI AUTO PUMP ❑ I. ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WI 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- 02. MONTHLY 0.2 GPH TEST [12. MONTHLY 0.2 GPH TEST [13. ANNUAL INTEGRITY TEST (0.1 GPH) ❑ 3. ANNUAL INTEGRITY TEST (0.1 GPH) ❑ 4. DAILY VISUAL CHECK CONVENTIONAL SUCTION SYSTEMS I CONVENTIONAL SUCTION SYSTEMS (Check all that apply) ❑ 5. DAILY VISUAL MONITORING OF PUMPING SYSTEM + TRIENNIAL PIPING INTEGRITY TEST (0.1 GPH) ❑ 5. DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM SAFE SUCTION SYSTEMS (NO VALVES IN BELOW GROUND PIPING): [16. TRIENNIAL INTEGRITY TEST (0.1 GPI ❑ 7. SELF MONITORING SAFE SUCTION SYSTEMS (NO VALVES IN BELOW MOUND PIPING): GRAVITY FLOW ❑ 7. SELF MONITORING ❑ 9. BIENNIAL INTEGRITY TEST (0.1 GPH) GRAVITY FLOW (Check all that apply): ❑ 8. 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 WI7TI AUDIBLE AND VISUAL ALARMS AND (Check one) ALARMS AND (Check one) ®a AUTO PUMP SHUT OFF WHEN A LEAK OCCURS ❑ UTO 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 S Pc NO AUTO PUMP SHUT OFF 11. AUTOMATIC LINE LEAK DETECTOR (3.0 GPH TEST) FLOW SHUT NAUTOMATIC LEAK DETECTOR OFF OR RESTRICTION ❑ 12. ANNUAL INTEGRITY TEST (0.1 GPA) ❑ 12. ANNUAL INTEGRITY TEST (0,] GPH) SUCTION/GRAVTTY 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 tial apply) ❑ 14. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF ❑ 14. CONTINUOUS SUMP SENSOR wTTHOUI AUTO PUMP SHUT OFF AUDIBLE AND VISUAL ALARMS AUDIBLE AND VISUAL ALARMS ❑ 15. AUTOMATIC LINE LEAK DETECTOR (3.0 GPH TEST) WITH 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) [117. DAILY VISUAL CHECK ❑ 17. DAILY VISUAL CHECK VIIL DISPENSER CONTAINMENT DISPENSERCONTAINMENI 468. ❑ 1. FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE ❑ 4. DAILY VISUAL CHECK 469. DATE INSTALLED ® 2. CONTINUOUS DISPENSER PAN SENSOR + AUDIBLE AND VISUAL ALARMS ❑ 5. TREucHA NER MONITORING ❑ 3. CONTINUOUS DISPENSER PAN SENSOR WI AUTO SHUT OFF FOR ❑ 6- NONE DISPENSER+ AUDIBLE AND VISUAL ALARMS DL OWNER/OPERATOR SIGNATURE I certify that the information provided herein is true and accurate to the best of my knowledge. SIGNA TOR DATE:/�'� d� azo. NAME OF OWNER/OPERATOR (print): + TITLE OF OWNER/OPERATOR:472. Permit Number (Agency use only) 473. Permit Approved By (Agency ase only) 474. Permit Expiration Date (Agency use only) 475.