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UNIFIED PROGRAM CONSOLIDATED FORM TANKS l UNDERGROUND STORAGE TANKS - TANK PAGE 2 VI. PIPING CONSTRUCTION (Check all that apply) Page of - UNDERGROUND PIPING ABOVEGROUND PIPING SYSTEM TYPE Q 1. PRESSURE E] 2. SUCTION D 3. GRAVITY 458 1. PRESSURE 2. SUCTION [:] 3. GRAVITY 459 CONSTRUCTION [:] 1. SINGLE WALL 3. LINED TRENCH 99. OTHER 460 1. SINGLE WALL E] 95. UNKNOWN 462 MANUFACTURER Pfl 2. DOUBLE WALL 95. UNKNOWN 2. DOUBLE WALL 99. OTHER MANUFACTURER A.O. Smith J 461 MANUFACTURER 463 M 1. BARE STEEL Q 6. FRP COMPATIBLE w/100% METHANOL 1. BARE STEEL 6. FRP COMPATIBLE W/100% METHANOL 2. STAINLESS STEEL 7. GALVANIZED STEEL E] Unknown 2. STAINLESS STEEL 7. GALVANIZED STEEL 3. PLASTIC COMPATIBLE W/ CONTENTS El 99. Other El 3. PLASTIC COMPATIBLE W/ CONTENTS 8. FLEXIBLE (HDPE) 99. OTHER 4. FIBERGLASS 8. FLEXIBLE (HDPE) F-1 4. FIBERGLASS 9. CATHODIC PROTECTION S. STEEL W/COATING 9. CATHODIC PROTECTION 464 [] 5. STEEL W/COATING E] 95. UNKNOWN 465 VII. PIPING LEAK DETECTION (Check all that apply) (A description of the monitoring program shall be submitted to the local agency.) UNDFHGR0UNDTMTR7- ABOVEGROUND PIPING SINGLE WALL PIPING 466 SINGLE WALL PIPING 462 PRESSURIZED PIPING (Check all that apply): PRESSURIZED PIPING (Checkall thatapply): 1. ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP SHUT E] 1. ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP OFF FOR LEAK, SYSTEM FAILURE, AND SYSTEM DISCONNECTION + SHUT OFF FOR LEAK, SYSTEM FAILURE, AND SYSTEM DISCONNECTION + AUDIBLE AND VISUAL ALARMS. AUDIBLE AND VISUAL ALARMS. 2. MONTHLY 0.2 GPH TEST Ej 2. MONTHLY 0.2 GPH TEST 3. ANNUAL INTEGRITY TEST (0.1 GPH) r -j 3. ANNUAL INTEGRITY TEST (0.1GPH) 4. DAILY VISUAL CHECK CONVENTIONAL SUCTION SYSTEMS CONVENTIONAL SUCTION SYSTEMS (Check all that apply) 5. DAILY VISUAL MONITORING OF PUMPING SYSTEM +TRIENNIAL PIPING F] 5. DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM INTEGRITY TEST (0.1 GPH) SAFE SUCTION SYSTEMS (NO VALUES IN BELOW GROUNDPIPING): F1 6. TRIENNIAL INTEGRITY TEST (0.1 GPH) 7. SELF MONITORING SAFE SUCTION SYSTEMS (NO VALVES IN BELOW GROUND PIPING): GRAVITY FLOW F-1 7. SELF MONITORING 9. BIENNIAL INTEGRITY TEST (0.1 GPH) GRAVITY FLOW (Check all that apply): 8. DAILY VISUAL MONITORING 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 one) ALARMS AND (Check one) Q a. AUTO PUMP SHUT OFF WHEN A LEAK OCCURS F-1 a AUTO PUMP SHUT OFF A LEAK OCCURS Q b. AUTO PUMP SHUT OFF FOR LEAKS, YSTEM FAILURE AND SYSTEM b AUTO PUMP SHUT OFF FOR AKS, 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 11. AUTOMATIC LEAK DETECTOR OFF OR RESTRICTION 12. ANNUAL INTEGRITY TEST (0.1 GPH) F-1 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 1 S. AUTOMATIC LINE LEAK DETECTOR (3.0 GPH TEST) SHUT OFF OR RESTRICTION 16. ANNUAL INTEGRITY TEST (0.1 GPH) F-1 16. ANNUAL INTEGRITY TEST (0.1 GPH) 17. DAILY VISUAL CHECK Q 17. DAILY VISUAL CHECK VIII. DISPENSER CONTAINMENT DISPENSER CONTAINMENT F] 1. FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE E] 4. DAILY VISUAL CHECK DATE INSTALLED 468 F] 2. CONTINUOUS DISPENSER PAN SENSOR + AUDIBLE AND VISUAL ALARMS E] 5. TRENCH LINER / MONITORING 2006 Q 3. CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR 6. NONE 469 DISPENSER + AUDIBLE AND VISUAL ALARMS IX. OWNER/OPERATOR SIGNATURE I certify that the information provided herein is true and accurate to the best of my knowledge. 9/27/07 NAME OF OWNER/OPRATOR(print) Daniel A Erickson Compliance Manager ermit NUm6e, or local use only) 473 Permit Approved (For local use only) ermrt xpvanon Date or local use only) UPCF U 2/99 revised) 12 Formerly SWRCB Form B