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• NIFIED PROGRAM CONSOLIDATED FORV TANK: TA8616660 PR #: PR02319(11 y*Lira U D STORAGETANKS- TANK PAGE2 FAC #, cAUB3B VL PIPING CONSTRUCTION (a.,kaudwvoy) PaF39L3 UNDERGROUND P1P196ABOVEGROUND PIPING SYSTEM TYPE IM I. PRESSURE ❑ 2. SUCTION Q 3. GRAVITY 456 0 1. PRESSURE ❑ 2. SUCTION Q 3. GRAVITY 0S9 CONSTRUCTION ❑ I. SINGLs WA6L 03. LINED TRI.NCH ❑ 99. OTHER "0 ❑ I. SINGLE WALL ❑ 95. UNKNOWN 462 �j 2. DOUBLE WALL❑95. UNKNOWN ❑ 2, DOUBLE WALL ❑ 99. OTHER MANUrACTURER TOTAL CONTAINMENT 461 MANUFACTUK£R "3 ❑ I. RARE STEEL ❑ 6. FRP COMPATIBLE w/ IW%METHANOL ❑ 1. BARE STEEL ❑ 6. FRP COMPATIBLE W IMA MET14MOL M 2. STAINLESS STEEL ❑ T GALVANIZED STEEL Q 2. STAINLESS STEEL ❑ 7. GALVANIZED STEEL M PLASTIC COMPATIBLE W/ CONTENTS ❑ 95. UNKNOWN ❑ PLASTIC COMPATIBLE W/ CONTENTS ❑ 95, UNKNOWN ❑ 4. FIBERGLASS ❑ S. FLEXIBLE (HDPE) Q 99. OTHER ❑ 4. FIBERGLASS ❑ S. FLEXIBLE own) ❑ 99. OTHER ❑ 5, STEEL W/C'OA'r1NG ® P. CATHODIC PROTECTION 4t ❑ 5. STEEL W/CoATINo ❑ 9. CATHODIC PRoTEcnON 409 VIL PIPING LEAK DETECTION (Cbtdt all dw awb9 (A ft local uwm..) UNDERGROUND PIPING ABOVEGROUND PIPING SINGLE WALL PIPING 465 SINGLE WALL MING 467 PRESSURIZED PIPING (Chock all that apply)- PRESSURIZED PIPING (Chock all that apply); ❑ 1. ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP SHUT OFF ® 1. ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP SHUT on FOR LEAK, SYSTEM FAILURE, AND SYSTEM DISCONNECTION+AUDIBLE AND FOR LEAK, SYSTEM FAILURE, AND SYSTEM DISCON NECTION+ AUDIBLE AND VISUAL ALARMS. VISUAL ALARMS. ❑ 2 MONTHLY 0,3 GPH TEST El 2 MONTHLY 0.2 GPH TEST ® 3. ANNUAL INTEGRITY TEST (0.1 GPH) © 3. ANNUAL INTEGRITY TEST (0, I GPH) ❑ 4. DAILY VISUAL CHECK CONVENTIONAL SUCTION SYSTILMS CONVENTIONAL SUCTION SYSTEMS (Chock all that 4PPlr) ® S. DAILY VISUAL MONITORING OF PUMPING SYSTEM+ TRIS• NNIEAL PIPING ❑ S. DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM INTEGRITY TOT (0,1 GPH) ® 6. TRIENNIAL mmol iTY rur (0.1 GPH) SAFE SUCTION SYSTEMS (NO VALUES 1N BELOW GROUND'PWING)t SAFE SUMON SYSTEMS (NO VALUES IN BYL.OW GROUNDPIPING): ❑ ?• SELF MONITORING ❑ 7. SELF MONITORING GRAVITY FLOW © •4. BIENNIAL INTEGRITY TEST (0, I) GPH GRAVITY FLOW (Chock all that apply): ❑ S, DAILY VISUAL MONITORING ❑ 9. BIENNIAL INTEGRITY TEST (0.1) GPH SECONDARILY CONTAINED PIPING SECONDARILY CONTAINED PIPING PRESSURIZED PIPING (Chuck all that apply): PRESSURIZED PIPING (Chock all that apply), 10. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL 10. CONTINUOUS TURBINE SUMP SENSOR W ITH AUDIBLE AND VISUAL ALARMS AND (Cba&aW ALARMS AND (Uma um) ® a. AUTO PUMP SHUT OFF WHEN A LEAK OCCURS ❑ a AUTO PUMP SHUT OFF WHEN A LEAK OCCURS ® b. AUTO PUMP SHUT OFF FOR LEAKS, SYSTEM FAILURE AND SYSTEM ❑ b. AUTO PUMP SHUTOFF FOR LEAKS. SYSTEM FAILURE AND SYSTEM DISCONNECTION DISCONNECTION o. NO AUTO PUMP SHUT OFF ® v. NO AUTO PUMP SHUT OPP ❑ 11. AUTOMATIC LINE LEAK DETECTOR (3.0 GPH TEST) WITH FLOW SHUT OFF OR ❑ 11. AUTOMATIC LEAK DETECTOR RESTRICTION ❑ 12. ANNUAL INTEGRITY TEST (D.1 GPH) ❑ 11. ANNUAL INTEGRITY TEST (0,1 GPH) SIICTION/GRA'VITY SYSTEM SUCTION/GRAVITY SYSTEM ❑ 13. CONTINUOUS SUMP SENSOR + AUDIBLE AND VISUAL ALARMS ❑ 13. CONTINUOUS SUMP SENSOR+ AUDIBLE AND VISUAL ALARMS EMERGENCY GENERATORS ONLY (Chock all dua Wly) EMERGENCY GENERATORS ONLY (Cheek as"mplr) ❑ 14, CONTINUOUS SUMP SENSOR WITHOt1T AUTO PUMP SHUT Off ❑ 14. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF • AUDIBLE AND VISUAL ALARMS rWDJBLE AND VISUAL ALARMS ❑ 13. AUTOMATIC LINE LEAK DET$CTOR (8,0 GPH TF T) WITHOUT FLOW p 15. AUTOMATIC LdNE LEAK DETECTOR (3.0 GPH TEST) WITHOUT PLOW SHUT OFF OR RESTRIMON SHUT Off OR RESTRICTION ® 16. ANNUAL INTEGRITY TEST(O, I GPH) ❑ 16, ANNUAL INTEGRITY TEST (O.I GPH) ® 17. DAILY VISUAL CHECK ❑ IT DAILY VISUAL CHECK VIII. DISPENSER CONTAINMENT DISPENSER CONTAINMENT ❑ 1. FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE ❑ 4. DAILY VISUAL CHECK DATE INSTALLED 461 2. CONTINUOUS DISPENSER PAN SENSOR + AUDIBLE AND VISUAL ALARMS ® ❑ 5. TRENCH LINER MONITORING ® 3. CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR ❑ 6. NONE DISPENSER+AUDIBLE AND VISUAL ALARMS 469 1X, OWNER/OPERATOR SIGNATURE I e4aI14 lam U. mGxnxti+Dn p q wmfferae to dw bell otmry 1krumiedip. •S1L9NA DATE� n 7 470 NAME OF OWNEWOPE TOR } TITLE OF OWNERIOPERATOR E G VV 471 LIEUTENANT 4r_ Rami Hmaba (Far local aolp) kwun Approved (Ya kvd ak 014') 474 Pe -a -i1 Expiswian Dia+ (For local uc4 aaly) 475 PT0005049 EE0003904 12/31/1999 12:00:®OA,M UPCF (12/9 rcni 60/80 39Vd NOIAD 1S dH0 T99BEP660ZT LZ:60 LOOZ{90/90