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PROGRAM CONSOLIDATED f aIA 11111u c VI. PIPING CONSTRUCTION (Check aE mat apply) SYSTEM TYPE ❑ 1. PRESSURE ❑ 2. SUCTION ❑ 3. GRAVITY 458 CONSTRUCTION [:11. SINGLE WALL 03. LINED TRENCH ❑ 99. OTHER 460 ❑ 2. DOUBLE WALL 095.UNKNOWN MANUFACTURER 461 ❑ 1. BARE STEEL ❑ 6. FRP COMPATIBLE w/ 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 464 VII. PIPING LEAK DETECTION (Check an mac .-Iwl (A a ............. �..........v 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 ❑ 5. DAILY VISUAL MONITORING OF PUMPING SYSTEM + TRIENNIEAL 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 (Chock 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) ❑ 17. DAILY VISUAL CHECK TANK: TA0505633 PR #: PR0504388 FAC #: FA0006185 Page 5 of 5 ❑ I. PRESSURE ❑ 2. SUCTION p 3. GRAVITY 459 ❑ I. SINGLE WALL ❑ 95. UNKNOWN 462 ❑ 2. DOUBLE WALL ❑ 99. OTHER MANUFACTURER 463 ❑ 1. BARE STEEL ❑ 6. FRP COMPATIBLE w/ 100% METHANOL ❑ 2. STAINLESS STEEL ❑ 7. GALVANIZED STEEL p PLASTIC COMPATIBLE W/ CONTENTS ❑ 95. UNKNOWN p 4. FIBERGLASS ❑ 8. FLEXIBLE (HDPE) ❑ 99. OTHER p 5. STEEL W/COATING ❑ 9. CATHODIC PROTECTION 465 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.I) 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 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 ❑ I5. AUTOMATIC LINE LEAK DETECTOR (3.0 GPH TEST) WITHOUT FLOW SHUT OFF OR RESTRICTION p 16. ANNUAL INTEGRITY TEST (0.1 GPH) ❑ 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 ❑ 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 accurate to the best of my knowledge. SIGNATURE OFOWNER/OPERATOR DATE J03 470 NAME OFNER/OOP TO�nt) 471 TITLE OF OWNER/ BATOR 472 Ei'lPT0008190 Number (For beal tae only) 473 Permit Approved (For local tae wily) 474 Pamit Expiration Date (For localuse only) 475 EE0000817 12/31/2003 UPCF (12/99 revised)