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IFIED PROGRAM CONSOLIDATED FOR TANK: TA0505632 PR #: PR0504388 UNDERGROUND STORAGE TANKS - TANK PAGE 2 FAC #: FA0006185 VI. PIPING CONSTRUCTION (Check all that apply) Page 3 of 5 UNDERGROUND PIPING ABOVEGROUND PIPING SYSTEM TYPE •❑ 1. PRESSURE [:12. SUCTION ❑ 3. GRAVITY 456 ❑ I. PRESSURE ❑ 2. SUCTION ❑ 3. GRAVITY 459 CONSTRUCTION ❑ 1. SINGLE WALL 03. LINED TRENCH ❑ 99. OTHER 460 ❑ 1. SINGLE WALL ❑ 95. UNKNOWN 462 ❑ 2. DOUBLE WALL E]95.UNKNOWN ❑ 2. DOUBLE WALL ❑ 99. OTHER MANUFACTURER 461 MANUFACTURER 463 ❑ I. BARE STEEL ❑ 6. FRP COMPATIBLE w/ 10D% METHANOL ❑ 1. BARE STEEL ❑ 6. FRP COMPATIBLE w/ 100% METHANOL ❑ 2. STAINLESS STEEL ❑ 7. GALVANIZED STEEL ❑ 2. STAINLESS STEEL ❑ 7. GALVANIZED STEEL ❑ PLASTIC COMPATIBLE W/ CONTENTS ❑ 95. UNKNOWN ❑ PLASTIC COMPATIBLE W/ CONTENTS ❑ 95. UNKNOWN ❑ 4. FIBERGLASS ❑ 8. FLEXIBLE (HDPE) ❑ 99. OTHER ❑ 4. FIBERGLASS ❑ 8. FLEXIBLE (HDPE) ❑ 99. OTHER ❑ 5. STEEL W/COATING ❑ 9. CATHODIC PROTECTION 464 ❑ 5. STEEL W/COATING ❑ 9. CATHODIC PROTECTION 465 VII. PIPING LEAK DETECTION (Check all that appl) (A description of the nwnitoring program shall be submitted to the 1«a1 a m B cY ) UNDERGROUND PIPING ABOVEGROUND PIPING SINGLE WALL PIPING 466 SINGLE WALL PIPING 467 PRESSURIZED PIPING (Check all that apply): PRESSURIZED PIPING (Check 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 OFF FOR LEAK, SYSTEM FAILURE, AND SYSTEM DISCONNECTION+ AUDIBLE AND FOR LEAK, SYSTEM FAILURE, AND SYSTEM DISCONNECTION+ AUDIBLE AND VISUAL ALARMS. VISUAL ALARMS. ❑ 2. MONTHLY 0.2 GPH TEST ❑ 2. MONTHLY 0.2 GPH TEST ❑ 3. ANNUAL INTEGRITY TEST (0.1 GPH) ❑ 3. ANNUAL INTEGRITY TEST (0.1 GPH) ❑ 4. DAILY VISUAL CHECK CONVENTIONAL SUCTION SYSTEMS CONVENTIONAL SUCTION SYSTEMS (Check all that apply) ❑ 5. DAILY VISUAL MONITORING OF PUMPING SYSTEM +TRIENNIEAL PIPING ❑ 5. DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEkq INTEGRITY TEST (0.1 GPH) ❑ 6. TRIENNIAL INTEGRITY TEST (0.1 GPH) SAFE SUCTION SYSTEMS (NO VALUES IN BELOW GROUNDPIPING): SAFE SUCTION SYSTEMS (NO VALUES IN BELOW GROUNDPIPING): ❑ 7. SELF MONITORING C]7. SELF MONITORING GRAVITY FLOW ❑ 9. BIENNIAL INTEGRITY TEST (0.1) GPH GRAVITY FLOW (Check all that apply): p 8. DAILY VISUAL MONITORING e p 9. BIENNIAL INTEGRITY TEST (0.1) GPH SECONDARILY CONTAINED PIPING SECONDARILY CONTAINED PIPING PRESSURIZED PIPING (Check all that apply): PRESSURIZED PIPING (Check all that apply): 10. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL 10. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL ALARMS AND (Check ate) ALARMS AND (Check ate) ❑ 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 SHUT OFF FOR LEAKS, SYSTEM FAILURE AND SYSTEM DISCONNECTION DISCONNECTION ❑ c. NO AUTO PUMP SHUT OFF ❑ c. NO AUTO PUMP SHUT OFF ❑ 11. AUTOMATIC LINE LEAK DETECTOR (3.0 GPH TEST) WITH FLOW SHUT OFF OR ❑ 11. AUTOMATIC LEAK DETECTOR RESTRICTION ❑ 12. ANNUAL INTEGRITY TEST (0.1 GPH) ❑ 12. ANNUAL INTEGRITY TEST (0.1 GPH) SUCTION/GRAVITY SYSTEM SUCTION/GRAVITY SYSTEM ❑ 13. CONTINUOUS SUMP SENSOR + AUDIBLE AND VISUAL ALARMS ❑ 13. CONTINUOUS SUMP SENSOR + AUDIBLE AND VISUAL ALARMS EMERGENCY GENERATORS ONLY (Check all that apply) EMERGENCY GENERATORS ONLY (Check all that apply) ❑ 14. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF * ❑ 14. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF ° AUDIBLE AND VISUAL ALARMS AUDIBLE AND VISUAL ALARMS ❑ 15. AUTOMATIC LINE LEAK DETECTOR (3.0 GPH TEST) WITHOUT FLOW ❑ 15. AUTOMATIC LINE LEAK DETECTOR (3.0 GPH TEST) WITHOUT FLOW SHUT OFF OR RESTRICTION SHUT OFF OR RESTRICTION ❑ 16. ANNUAL INTEGRITY TEST (0.l GPH) ❑ 16. ANNUAL INTEGRITY TEST (0.1 GPH) ❑ 17. DAILY VISUAL CHECK ❑ 17. DAILY VISUAL CHECK VIII. DISPENSER CONTAINMENT DISPENSER CONTAINMENT ❑ I. FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE ❑ 4. DAILY VISUAL CHECK DATE INSTALLED 466 ❑ 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 IX. OWNER/OPERATOR SIGNATURE I curdy that the infortnalion provided herein is true and accurate to the best of my knowledge. SIGNATURE OF OWNER/OPERATOR DATE J O- 470 NAME OF OWNER/OPERATOR (print) r 471 TITLE OF OWNER/OPERATOR 472 fPTPcrngIumber (For local use only) 473 Permit Approved (For local use only) 474 Petmit Expiration Date (For local use only) 475 0008190 EE0000817 12/31/2003 UPCF (12/99 revised)