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SYSTEM TYPE ❑ 1. PRESSURE CONSTRUCTION ❑ 1. SINGLE WALL $1SL 2. DOUBLE WALL MANUFACTURER! �� & (b 0 10 UNIFIED PROGRAM CONSOLIDATED FOdGE TANK: TA0425103 PR #: PRO234251 UNDERGROUND STORAGE TANKS - TANK P 2 FAC #: FA0003508 VI. PIPING CONSTRUCTION (Check all that apply) Page 3 of 5 l2. SUCTION ❑ 3. GRAVITY ❑3. LINED TRENCH ❑ 99. OTHER ❑95. UNKWWN A _ _ !I 458 460 461 ❑ 1. BARE STEEL ❑ 6. FRP COMPATIBLE w/ 100% METHANOL ❑ 2. STAINLESS STEEL 19 7. GALVANIZED STEEL ❑ PLASTIC COMPATIBLE W/ CONTENTS ❑ 95. UNKNOWN . FIBERGLASS ❑ 8. FLEXIBLE (HDPE) ❑ 99. OTHER ❑ 5. STEEL W/COATING ❑ 9. CATHODIC PROTECTION 464 ❑ 6. FRP COMPATIBLE./ 100%METHANOL VII. PIPING LEAK DETECTION (Check all that apply) (A ❑ 7. GALVANIZED STEEL UNDERGROUND PIPING SINGLE WALL PIPING 466 PRESSURIZED PIPING (Check all that apply): ❑ 1. ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP SHUT OFF FOR LEAK, SYSTEM FAILURE, AND SYSTEM DISCONNECTION+ AUDIBLE AND VISUAL ALARMS. ❑ 2. MONTHLY 0.2 GPH TEST ❑ 3. ANNUAL INTEGRITY TEST (0.1 GPH) CONVENTIONAL SUCTION SYSTEMS ❑ S. DAILY VISUAL MONITORING OF PUMPING SYSTEM + TRIEN ZEAL PIPING INTEGRITY TEST (0.1 GPH) SAFE SUCTION SYSTEMS (NO VALUES IN BELOW GROUNDPIPING): ❑ 7. SELF MONITORING GRAVITY FLOW ❑ 9. BIENNIAL INTEGRITY TEST (0.1) GPH SECONDARILY CONTAINED PIPING PRESSURIZED PIPING (Check all that apply): 10. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL ALARMS AND (Check one) ❑ a. AUTO PUMP SHUT OFF WHEN A LEAK OCCURS ❑ b. AUTO PUMP SHUT OFF FOR LEAKS, SYSTEM FAILURE AND SYSTEM DISCONNECTION ❑ c. NO AUTO PUMP SHUT OFF ❑ 11. AUTOMATIC LINE LEAK DETECTOR (3.0 GPH TEST) WITH FLOW SHUT OFF OR RESTRICTION ❑ 12. ANNUAL INTEGRITY TEST (0.1 GPH) SUCTION/GRAVITY SYSTEM ❑ 13. CONTINUOUS SUMP SENSOR + AUDIBLE AND VISUAL ALARMS EMERGENCY GENERATORS ONLY (Check all that apply) ❑ 14. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF " AUDIBLE AND VISUAL ALARMS ❑ 15. AUTOMATIC LINE LEAK DETECTOR (3.0 GPH TEST) WITHOUT FLOW SHUT OFF OR RESTRICTION ❑ I . PRESSURE ❑ 2. SUCTION ❑ 3. GRAVITY 459 ❑ 1. SINGLE WALL ❑ 95. UNKNOWN 462 ❑ 2. DOUBLE WALL ❑ 99. OTHER MANUFACTURER 463 ❑ 1. BARE STEEL ❑ 6. FRP COMPATIBLE./ 100%METHANOL ❑ 2. STAINLESS STEEL ❑ 7. GALVANIZED STEEL ❑ PLASTIC COMPATIBLE W/ CONTENTS ❑ 95. UNKNOWN ❑ 4. FIBERGLASS ❑ 8. FLEXIBLE (HDPE) ❑ 99. OTHER ❑ 5. STEEL W/COATING ❑ 9. CATHODIC PROTECTION 465 of the monitoring program shall be submitted to the local .,....,.......-............ 467 PRESSURIZED PIPING (Check all that apply): ❑ 1. ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP SHUT OFF FOR LEAK, SYSTEM FAILURE, AND SYSTEM DISCONNECTION+AUDIBLE AND VISUAL ALARMS. ❑ 2. MONTHLY 0.2 GPH TEST ❑ 3. ANNUAL INTEGRITY TEST (0.1 GPH) ❑ 4. DAILY VISUAL CHECK CONVENTIONAL SUCTION SYSTEMS (Check all that apply) ❑ 5. DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM ❑ 6. TRIENNIAL INTEGRITY TEST (0.1 GPH) SAFE SUCTION SYSTEMS (NO VALUES IN BELOW GROUNDPIPING): ❑ 7. SELF MONITORING GRAVITY FLOW (Check all that apply): ❑ 8. DAILY VISUAL MONITORING ❑ 9. BIENNIAL INTEGRITY TEST (0.1) GPH SECONDARILY CONTAINED PIPING PRESSURIZED PIPING (Check all that apply): 10. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL ALARMS AND (Check are) ❑ a. AUTO PUMP SHUT OFF WHEN A LEAK OCCURS ❑ b. AUTO PUMP SHUT OFF FOR LEAKS, SYSTEM FAILURE AND SYSTEM DISCONNECTION ❑ c. NO AUTO PUMP SHUT OFF ❑ 11. AUTOMATIC LEAK DETECTOR ❑ 12. ANNUAL INTEGRITY TEST (0.1 GPH) SUCTION/GRAVITY SYSTEM ❑ 13. CONTINUOUS SUMP SENSOR + AUDIBLE AND VISUAL ALARMS EMERGENCY GENERATORS ONLY (Check all that apply) ❑ 14. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF " AUDIBLE AND VISUAL ALARMS ❑ 15. AUTOMATIC LINE LEAK DETECTOR (3.0 GPH TEST) WITHOUT FLOW SHUT OFF OR RESTRICTION ❑ 16. ANNUAL INTEGRITY TEST (0.1 GPH) ❑ 16. ANNUAL INTEGRITY TEST (0.1 GPH) ❑ 17. DAILY VISUAL CHECK ❑ 17. DAILY VISUAL CHECK VIII. DISPENSER CONTAINMENT DISPENSER CONTAINMENT ❑ 1. FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE ❑ 4. DAILY VISUAL CHECK DATE INSTALLED 468 ❑ 2. CONTINUOUS DISPENSER PAN SENSOR + AUDIBLE AND VISUAL ALARMS ❑rrrSSS 5. TRENCH LINER / MONITORING ❑ 3. CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR 6. NONE DISPENSER + AUDIBLE AND VISUAL ALARMS 469 IX. OWNER/OPERATOR SIGNATURE I certify that the information provided herein is true and amvate to the best of my knowledge. SIUNAT O N OP RATOR DATE '7/1 143 470 NAME OF O ER/OPERATOR (p 'nt TITLE OF OWNER//OPERATOR 471 . rj. 472 Permit Number (For local use only) 473 O Permit Approved (For local use only) 474 r Pernit Expiration Date (For local use only) 475 PT0003365 EE0003804 1/1/1993 UPCF (12/99 revised)