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NIFIED PROGRAM CONSOLIDATED FORM TANKS UNDERGROUND STORAGE TANKS•TANK RAGE 2 VL PIPWG CONSTRUCTION(Check s0 0het epptyj UNDERGROUND PIPING SYSTEM TYPE ABOYEGRWND PIPING 1 PRESSURE ❑2. SUCTION ❑ 3. GRAVITY ❑ 1. PRESSURE ❑ 1 SINGLE-NALL ❑ 3. LINEDTRENCM ❑ 2. SUCTION ❑ 3. GRAVITY CONSTRUCTION! �y ❑99. OTHER ❑ 1. SINGLE WALL ❑95. UNKNOWN MANUFACTURER }24 2 DOUBLE WAIL ❑95, UNKNOWN 7� ❑2. DOUBLE WALL ❑SS. OTHER MANUFACTURER MANUFACTURER ❑ 1.BARE STEEL ❑6.FRP COMPATIBLE Wt 100%METHANOL ❑ 1.BARE STEEL MATERIALS ANO ❑2 STAINLESS STEEL ❑ T.GALVANIZED$TEFL ❑6. FRP COMPATIBLE VW.100%METHANOL CORROSION ❑ 2. STAINLESS STEEL ❑ P. GALVANIZED STEEL PROTECTION ❑ 3. PLASTIC COMPATIBLE"TH CONTENTS ❑95 UNKNOWN ❑ 3. PLASTIC COMPATIBLE WITH CONTENTS ❑ S. FLEXIBLE(MOPE) ❑99.OTHER 4. FIBERGLASS ❑6. FLEXIBLE(HOPE) 1199. OTHER ❑ 4. FIBERGLASS ❑ 5. STEEL VW COATING Cl 9_CATHODIC PROTECTION 119. CATHODIC PROTECTION ❑ s. STEEL WW COATING ❑95.UNKVOWN VIL PIPING LEAK DETECTION(Check at that eppuy) UNDERGROUND PIPING SINGLE WALL PIPI ASOVEGROUNDPIPING PRESSURIZED PIPING(Check DIN that appW: PRESSURIZED PIPING(Chock am Mat apply).SINGLE WALL PIPING ❑ 1 ELECTRONIC LINE LEAK DETECTOR 3.0 GPM TEST WITH AUTO PUMP SHUT OFF FOR ❑ 1. ELECTRONIC LINE LEAK DETECTOR 3.0 GPM TEST WITH AUTO PUMP$HUT OFF FOR LEAK, LEAK.SYSTEM FAILURE.AND SYSTEM DISCONNECTION+AUDIBLE AND VISUAL SYSTEM FAILURE,AND SYSTEM DISCONNECTION+AUDIBLE AND VISUAL ALARMS ALARMS ❑ 2. MONTHLY 0.2 GPM TEST ❑ 2. MONTHLY 02 GPM TEST ❑ 3 ANNUAL INTEGRITY TEST(0.I GPM) ❑ 3.ANNUAL INTEGRITY TEST(0.1 GPM) ❑ 4. DAILY VISUAL CHECK CONVENTIONAL SUCTION SYSTEMS CONVENTIONAL SUCTION SYSTEMS(Check am mat appy). ❑ S DAILY VISUAL MONITORING OF PUMPING SYSTEM-TRIENNIAL PIPING INTEGRITY ❑ 5.DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM TEST(0 1 GPM) ❑ 6. TRIENNIAL INTEGRITY TEST(0.1 G" SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING) SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): ❑ P SELF MONITORING ❑ P. SELFMONITORING, GRAVITY FLOW ❑ GRAVITY FLOW{Chock ap that appgW:9. BIENNIAL INTEGRITY TEST(O.t GPM) ❑ 8. DAILY VISUAL MONITORING ❑ 9 BIENNIAL INTEGRITY TEST(O.1 GPM) SECONDARILY CONTAINED PIPING PRESSURIZED PIPING(Check a*Mat aWy)_ SECONDARILY CONTAINED PIPING PRESSURIZED PIPING{Check as(hot appy)* 10 CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL ALARMS AND it ck°"e) 10.CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL ALARMS AND(chea one) a AUTO PUMP SHUT OFF WHEN A LEAK OCCURS ❑ a.AUTO PUMP SHUT OFF WHEN A LEAK OCCURS ❑° DUSCONNECTO PMP710NT OFF FOR LEAKS.SYSTEM FAILURE AND SYSTEM Clb AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM DISCONNECTION ❑ C. NO AUTO PUMP SHUT OFF 13 G NO AUTO PUMP SHUT OFF Cl 11 AUTOMATIC UNE LEAK DETECTOR(3.0 GPM TEST)WITH FLOW SHUT OFF OR RESTRICTION Q 11. AUTOMATICLEAK DETECTOR 12 ANNUAL INTEGRITY TEST(0.1 GPM) ❑ 12. ANNUAL INTEGRITY TEST(0.1 GPM) SUCTION/GRAVITY SYSTEM: SUCTION/GRAVITY SYSTEM. Cl 13 CONTINUOUS SUMP SENSOR+AUDI8LE AND VISUAL ALARMS ❑ 13 CONTINUOUS SUMP SENSOR.AUDIBLE AND VISUAL ALARMS EMERGENCY GENERATORS ONLY(Chock as drat apply) EMERGENCY GENERATORS ONLY(Chock 411 NM apply) ❑ 14. CONTINUOUS SUMP SENSOR VH'TMOU7 AUTO PUMP SHUT OFF•AUDIBLE AND VISUAL ALARMS ❑ 14. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF+AUDIBLE AND VISUAL ALARMS ❑ 15 AUTOMATIC UNE LEAK DETECTOR 1110 GPM TEST)WITHOUT FLOW SHUT OFF OR ❑ 15 AUTOMATIC LINE LEAK DETECTOR(3.0 GPM TEST) RESTRICTION ❑ 16. ANNUAL INTEGRITY TEST(0.1 GPM) ❑ 16.ANNUAL INTEGRITY TEST(0.T GPM) ❑ tP. DAILY VISUAL CHECK ❑ 1P. DAILY VISUAL CHECK VIE.DISPENSER CONTAINMENT DISPENSER CONTAINMENT ❑ 1. FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE ❑ 4. DAILY VISUAL CHECK DATE INSTALLED ❑2. CONTINUOUS DISPENSER PAN SENSOR•AUDIBLE AND VISUAL ALARMS ❑ 5. TRENCH LINER t MONITORING 3.CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SMUT OFF FOR DISPENSER s AUDIBLE AND VISUAL ALARMS ❑e. NONE Ot OWNEMOPERATOR SIGNATURE I cerbry that M*mtohnauon provi4g4 h~Is sue arW aaurate W Cts pari of mY knowleCge. SIGNATURE OF OWNERIOPERATOR DATE 1O � pl NAME OF OW NER/OPERATOR(p" TI7'7LF� F pWNEWOPERATOR v� / EP Parm;t NumJer(Farwm we°nty) POMA Approv44(Fpr(scot uaa pMy) POat$t Elroh Dab(Far beat usa°`NIW UPAFORM 141991