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UNIFIED PROGRAM CONSOLIDATED FORM TANKS UNDERGROUND STORAGE TANKS - TANKPAGE 2 /3) Paoe_ of _ ' VI.PIPING CONSTRUCTION(Check at fMf apply UNDERGROUND PIPING ABOVEGROUND PIPING SYSTEM TYPE ❑ 1. PRESSURE 2. SUCTION ❑ 3. GRAVITY ❑ 1. PRESSURE ❑ 2. SUCTION ❑_ 3 GRAVITY CONSTRUCTION/ ❑ 1 SINGLE WALL ❑ 3. LINED TRENCH ❑99. OTHER ❑ 1 SINGLE WALL ❑95. UNKNOWN MANUFACTURER ❑ 2 DOUBLE WALL ❑9S. UNKNOWN ❑ 2. DOUBLE WALL ❑99. OTHER MANUFACTURER MANUFACTURER _ ❑ 1,BARE STEEL ❑ 6. FRP COMPATIBLE W/100%METHANOL ❑ V BARE STEEL ❑ 6. FRP COMPATIBLE W!100%METHANOL MATERIALS AND ❑ 2. STAINLESS STEEL ❑ 7.GALVANIZED STEEL ❑ 2. STAINLESS STEEL ❑ 7. GALVANIZED STEEL CORROSION PROTECTION ❑ 3. PLASTIC COMPATIBLE WITH CONTENTS 1195 UNKNOWN ❑ 3. PLASTIC COMPATIBLE WITH CONTENTS ❑ 6. FLEXIBLE(HDPE) ❑99. OTHER 4. FIBERGLASS _❑ 6. FLEXIBLE(HOPE) ❑99. OTHER ❑ 4. FIBERGLASS ❑ 9.CATHODIC PROTECTION ❑ 5. STEEL W/COATING ❑ 9.CATHODIC PROTECTION ❑ 5. STEEL W/COATING ❑95. UNKNOWN VII.PIPING LEAK DETECTION(Check alf that appy) _ UNDERGROUND PIPING ABOVEGROUND PIPING I SINGLE WALL PIPING SINGLE WALL PIPING PRESSURIZED PIPING(Check DIA that appy): PRESSURIZED PIPING(Check aA that appy). ❑ 1 ELECTRONIC LINE LEAK DETECTOR 3.0 GPM TEST WITH AUTO PUMP SHUT OFF FOR ❑ 1. ELECTRONIC LINE LEAK DETECTOR 3.0 GPM TEST WITH AUTO PUMP SHUT OFF FOR LEAK. LEAK.SYSTEM FAILURE.AND SYSTEM OISCONNECTION a AUDIBLE AND VISUAL SYSTEM FAILURE,AND SYSTEM DISCONNECTION AUOIBLE AND VISUAL ALARMS ALARMS ❑ 2. MONTHLY 0 2 GPM TEST ❑ 2 MONTHLY 0 2 GPM TEST ❑ 3. ANNUAL INTEGRITY TEST(0.1 GPM) ❑ 3 ANNUAL INTEGRITY TEST(0.1 GPM) ❑ 4. DAILY VISUAL CHECK CONVENTIONAL SUCTION SYSTEMS: CONVENTIONAL SUCTION SYSTEMS(Check all that apply)* ❑ 5 DAILY VISUAL MONITORING OF PUMPING SYSTEM-TRIENNIAL PIPING INTEGRITY ❑ S. DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM TEST(0 1 GP/I, ❑ 6 TRIENNIAL INTEGRITY TEST(0.1 GPM) SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): ❑ 7. SELF MONITORING ❑ 7. SELF MONITORING GRAVITY FLOW. GRAVITY FLOW(Check ea that apply):BIENNIAL INTEGRITY TEST(0.1 GPM) ❑ $, DAILY VISUAL MONITORING ❑ 9. BIENNIAL INTEGRITY TEST(0.1 GPM) SECONDARILY CONTAINED PIPING SECONDARILY CONTAINED PIPING PRESSURIZED PIPING(Check ell that appy): PRESSURIZED PIPING(Chock as that apply): 10. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL ALARMS AND (Chock one) 10.CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL ALARMS AND(check one) ❑ a AUTO PUMP SHUT OFF WHEN A LEAK OCCURS ❑ a. AUTO PUMP SMUT OFF WHEN A LEAK OCCURS Cl b AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAlll'RE AND SYSTEM DISCONNECTION ❑ b. AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM DISCONNECTION ❑ c. NO AUTO PUMP SHUT OFF ❑ e. NO AUTO PUMP SHUT OFF ❑ 11. AUTOMATIC LINE LEAK DETECTOR(3.0 GPM TEST)WITH FLOW SHUT OFF OR RESTRICTION ❑ 91. AUTOMATIC LEAK DETECTOR ❑ 12 ANNUAL INTEGRITY TEST(0.1 GPM) ❑ 12. ANNUAL INTEGRITY TEST(0.1 GPM) SUCTIOWGRAVITY SYSTEM. SUCTION/GRAVITY SYSTEM; 13. CONTINUOUS SUMP SENSOR♦AUDIBLE AND VISUAL ALARMS ❑ 13. CONTINUOUS SUMP SENSOR•AUDIBLE AND VISUAL ALARMS EMERGENCY GENERATORS ONLY(Cheek of 0st appy) EMERGENCY GENERATORS ONLY(Check 0 that apply) ❑ 14. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF•AUDIBLE AND ❑ 14. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF a AUDIBLE AND VISUAL VISUAL ALARMS ALARMS ❑ 15 AUTOMATIC LINE LEAK DETECTOR(3.o GPM TEST)WITHOUT FLOW SHUT OFF OR ❑ 15. AUTOMATIC UNE LEAK DETECTOR(3.0 GPH TEST) RESTRICTION ❑ 16. ANNUAL INTEGRITY TEST(0.1 GPH) ❑ 16. ANNUAL INTEGRITY TEST(0.1 GPM) ❑ 17. DAILY VISUAL CHECK ❑ 17. DAILY VISUAL CHECK VHI DISPENSER CONTAINMENT DISPENSER CONTAINMENT ❑ 1. FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE ❑ 4. DAILY VISUAL CHECK DATE INSTALLED IN 2. CONTINUOUS DISPENSER PAN SENSOR•AUDIBLE AND VISUAL ALARMS ❑ S. TRENCH LINER/MONITORING ❑ 3. CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR DISPENSER•AUDIBLE AND VISUAL ALARMS ❑ 0. NONE IX OWNER/OPERATOR SIGNATURE 1 urufy tmal the Intormsbon Provided herein is bve and acaxate to the bell of my knowledge. SIGNATURE OF OWNERIOPERATORt DATE w�±E QF OW`!ER/OPERATOR(W" TIW OF ONNEW0PERA70R Permit Number(Fa bcaf use onW Permit Approved(Forkwof vee DPW Permit Expiration Date(fa kxel use only) CUPAFORM(4/99) Formerly SWRCR Form 8