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UNIFIED PROGRAM CONSOLIDATED FORM l6 TANKS UNDERGROUND STORAGE TANKS - TANK PAGE 2 Of VI. PIPING CONSPRUCUIUN (Check all that apply) UNDERGROUND PIPING ABOVEGROUND PIPING SYSTEM TYPE 15(l.PR[3I. ESSURE 2. SUCTION ❑ 3. GRAVITY 458. ❑ 1. PRESSURE [12. SUCTION [13. GRAVITY 459. CONSTRUCTION/ it I. SINGLE WALL ❑ 3. LINED TRENCH [199. OTHER 460. ❑ I. SINGLE WALL [195, UNKNOWN 462. MANUFACTURER `jjC2 DOUBLE WALL ❑ 95. UNKNOWN ❑ 2. DOUBLE WALL [:199. OTHER MANUFACTURER SM(Ti1 fi,60RC LST 461. MANUFACTURER 463' ❑ I. BARE STEEL 'A 6. FRP COMPATIBLE W/100% METHANOL ❑ I. BARE STEEL ❑ 6. FRP COMPATIBLE W/100% METHANOL [12. STAINLESS STEEL [17. GALVANIZED STEEL ❑ 2. STAINLESS STEEL ❑ 7. GALVANIZED STEEL [13. PLASTIC COMPATIBLE WITH CONTENTS ❑ 95. UNKNOWN ❑ 3. PLASTIC COMPATIBLE W/ CONTENTS ❑ 8. FLEXIBLE (HDPE) ❑ 99. OTHER FIBERGLASS [18. FLEXIBLE (HDPE) ❑ 99. OTHER [14. FIBERGLASS ❑ 9. CATHODIC PROTECTION ❑ 5. STEEL W/COATING ❑ 9. CATHODIC PROTECTION 464. [15. STEEL W/COATING [195. UNKNOWN a65. -innrmo nroaram shall be submitted to the local agency.) 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 [13, ANNUAL INTEGRITY TEST (0.1 GPH) CONVENTIONAL SUCTION SYSTEMS ❑ 5. DAILY VISUAL MONITORING OF PUMPING SYSTEM + TRIENNIAL PIPING INTEGRITY TEST (0.1 GPH) SAFE SUCTION SYSTEMS (NO VALVES IN BELOW GROUND PIPING): ❑ 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 ❑ 16. ANNUAL INTEGRITY TEST (0.1 ❑ 17. DAILY VISUAL CHECK DISPENSER CONTAINMENT 468. DATEINSTALLED I certify that the infolmItijon vide( SIGNATUREOFO DR S NAME O N PE t�}I�' Pennit Number (Agency use only) 1 SINGLE WALL PIPING 467. PRESSURIZED PIPING (Check all that apply): ❑ I. 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 [16. TRIENNIAL INTEGRITY TEST (0.1 GPH) SAFE SUCTION SYSTEMS (NO VALVES IN BELOW GROUND PIPING): ❑ 7. SELF MONITORING GRAVITY FLOW (Check all that apply): [18. DAILY VISUAL MONITORING C]9. BIENNIAL INTEGRITY TEST (0.1 GPH) SECONDARILY CONTAINED PIPING PRESSURIZED PIPING (Check all that apply): l0. 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 ❑ 15. AUTOMATIC LINE LEAK DETECTOR (3.0 GPH TEST) GPH) I [116. ANNUAL INTEGRITY TEST (0.1 GPH) [117. DAILY VISUAL CHECK VIII. DISPENSER CONTAINMENT ❑ 1. FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE ❑ C12. CONTINUOUS DISPENSER PAN SENSOR+ AUDIBLE AND VISUAL ALARMS ❑ V3. CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR ❑ DISPENSER+ AUDIBLE AND VISUAL ALARMS IX, OWNER/OPERATOR SIGNATURE herein is true and accurate to the best of my knowledge. DATE: 7l l� DCS I TITIN QF,Qy✓jltbR/ RATOR: t A~ 473. 1 Permit Approved By (Agency use only) 474. UPCF hwfwrc-b (1/99) - 3/4 http://www.tinidocs.org 4. DAILY VISUAL CHECK 469. 5. TRENCH/LINER MONITORING 6. NONE use only) 475.