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NIFIED PROGONSOLlDATE <br /> U <br /> INDERGROUND STORAGE TANKS-TANK PAGE 2 TANKS <br /> UNDERGROUND PIPING VL P1PW4 CONSTRUCTON MhOCk 00 8W Opp" <br /> SYSTEM TYPEABOVEGROUNDMPING <br /> r I PRESSURE CJ 2 SUCTION 0 3. GRAVITY 13 1. PRESSURE <br /> ❑CONSTRUCTION., 0 1 SINGLE WALL 0 3 rmll - SUCTION LINED 11 OTHER 3. GRAVITY <br /> MANUFACTURER 2 DOUBLE WALL 1385. UNKNOWN 0 1 SINGLE ❑95. UNKNOWN <br /> MANUFACTURER 13 2- DOUBLE WALL ❑99 OTHER <br /> I BARE STEEL MANUFACTURER <br /> COMPATIBLE W/9001e METHANOL 1-BARE STEEL <br /> MATERIALS AND 0 2 STAINLESS STEEL ❑11 T. GALVANIZED STEEL 2 STAINLESS STEEL 13a. ERE COMPATIBLE Wt 100%METHANOL <br /> CORROSION <br /> PROTECTION 0 3. PLASTIC COMPATIBLE-WITH CONTENTS 0 95, UNKNOWN 3 PLASTIC COMPATIBLE WITH CONTENTS ❑11 7 GALVANIZED STEEL <br /> V,4. FIBERGLASS 0 e FLIEMBLE(HOPE) 0 99, OTHER 4 FIBERGLASS 0. FLEXIBLE(HOPE) 99.OTHER <br /> 0 5, STEEL kw rn­-, m - CATffOO10 PROTECTION S. STEEL M COATING ❑ <br /> 9, CATHODIC PROTECTION <br /> 0 95 UNKNOWN <br /> SINGILE WALL PIPING VN.PIPING LJEAK 0ETEC'n0N jChsek am mat apply; <br /> ABOVEGROUNIOPIPING <br /> PRESSURIZED PIPING(Chock all that appy): <br /> PRESSURIZED PIPING Mh@c*'Oaw <br /> 0 1 ELECTRONIC LINE LEAK DETECTOR 3.0 GPM TEST WITH AUTO PUMP SHUT OFF FOR 11 1 ELECTRONIC LINE LEAK DETECTOR&D GPM TEST WITH AUTO PUMP SHUT OFF FOR LEAK, <br /> LEAK,K SYSTEM FAILURE.AND SYSTEM DISCONNECTIFY-AUDIBLE AND VISUAL SYSTEM FAILURE,AND SYSTEM EA <br /> ALARMS <br /> 11 2 MONTHLY 0.2 GPM TEST 0 2 MONTHLY 0.2 GPM TEST DISCONNECTION;AUDIBLE AND VISUAL ALARMS <br /> 3 ANNUAL INTEGRITY TEST(0.1 GPM) 0 3.ANNUAL INTEGRITY TEST(0.1 GPM) <br /> El 4 DAILY VISUAL CHECK <br /> CONVENTIONAL SUCTION SYSTEMS CONVENTIONAL SUCTION SYSTEMS(Check a#that apply) <br /> 0 5 DAILY VISUAL MONITORING OF PUMPING SYSTEM-TRIENNIAL PIPING INTEGRITY 13 5- DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM <br /> TEST(a I GPM) <br /> WE SUCTION SYSTEMS(NO VALVES INBELOWGROUND PIPING) s TRIENNIAL INTEGRITY TEST(0.1 GPH) <br /> 11 7 SELF MONITORING SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): <br /> GRAVITY FLOW 13 7 SELF MONITORING <br /> 11 9 BIENNIAL INTEGRITY TEST(0.1 GPM) GRAVITY FLOW(Chao all that AppW: <br /> 0 8 DAILY VISUAL MONITORING <br /> 0 9 BIENNIAL INTEGRITY TEST(0.1 GPM) <br /> SECONDARILY CONTAINED PIPING <br /> PRESSURIZED PIPING(Chat'as that apply) PI <br /> PRESSURIZED PIPING{Chet'an that SECONDARILY CONTAINED PING <br /> 10 CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL ALARMS AND apply) <br /> X(Check ona) 10.CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL ALARMS AND a <br /> ALTO PUMP SHUT OFF WHEN A LEAK OCCURS ch ci,one) <br /> ❑ <br /> 0 b AUTO PUMP SHUT OFF FOR LEAKS.SYSTEM FAILURE AND SYSTEM a. AUTO PUMP SHUT OFF WHEN A LEAK OCCURS <br /> D,SCONNECTION b AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM DISCONNECTION <br /> NO AUTO PUMP SHUT OFF <br /> 0 11 AUTOMATIC LINE LEAK DETECTOR(3.0 GPM TEST)4!B!FLOW SHUT OFF 13 C_ NO AUTO PUMP SmVr OFF <br /> RESTRICTION OR 0 11 AUTOMATIC LEAK DETECTOR <br /> 12 ANNUAL INTEGRITY TEST(0.1 GPM) 11 12 ANNUAL INTEGRITY TEST(0.1 GPM) <br /> MtIONIGRAVITY SYSTEM <br /> C1 13 CONTINUOUS SUMP SENSOR-AUDIBLE AND VISUAL ALARMS SUCTIOFWGRAVITY SYSTEM, <br /> 013 CONTINUOUS SUMP SENSOR-AUDIBLE AND VISUAL ALARMS <br /> EMERGENCY GENERATORS ONLY(Ch&oa,dw OAVI❑ <br /> 14, CONTINUOUS SUMP SENSOR tMOUT AUTO PMP SHUTOFF-AUDIBLE AND15MERGENCY GENERATORS ONLY IIII So Mgt OpW <br /> VISUAL ALARMS E3 14 CONTINUOUS SLJM9 SENSOR WITHOUT AUTO PUMP SHUT OFF AUDIBLE AND VISUAL <br /> ❑ 15 AUTOMATIC LINE LEAK DETECTOR(3 0 GPM TEST)WITHOUT FLOW SHUT OFF OR <br /> ALARMS <br /> RESTRII 015 AUTOMATIC LINE LEAK DETECTOR(3.0 GPM TEST) <br /> 0 16 ANNUAL INTEGRITY TEST pi GPM) 016 ANNUAL INTEGRITY TEST(0,1 GPM) <br /> ❑ 17 DAILY VISUAL CHECK <br /> 1017. DAILY VISUAL CHECK <br /> VIN.DISPEMR CONTAMMT <br /> DISPENSER CONTAINMENT ❑ 1 FLOAT MECHANISM THAT SMUTS OFF SHEAR VALVE 0 4 0AtLVWSUA1 CHECK <br /> DATE INSTALLED 2. CONTINUOUS DISPENSER PAN SENSOR-AUDIBLE AND VISUAL ALARMS <br /> 0 S. TRENCH LINER/MONITORING <br /> pq 3-CONTINUOUS DISPENSER PAN 3tN30R WITH AUTO SHUT OFF FOR DISPENSER-AUDIBLE AND VISUAL ALARMS E3 A. NONE <br /> I COMFY that IhO mfOftawn provided how is Due am amrate to the be,of my kmvAoqe DL OWNERfOPERATOR SIGNATURE <br /> 'y that <br /> .... <br /> !AIURE 0 <br /> SIGNATURE OF ;?PF.RATOR <br /> -DATE, <br /> .0 0_, <br /> rNAMF F . mop <br /> E OF OWNE —L—LY <br /> TITLA OVMERATOR <br /> Permit N.mbw(F-kcW,,,@ Orejy) <br /> K ApprovW(Fo,Facm u"OW <br /> Pom POfmIt ExPwstlon Dow Ifor keel use*nW <br /> UPAFORM(4J991 <br />