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UNIFIED PROGRAM CONSOLIDATED FORM TANKS oll UNDERGROUND STORAGE TANKS - TANK PAGE i �\\ VI. PIPING CONSTRUCTION (Check all that apply) Page of UNDERGROUND PIPING ABOVEGROUND PIPING SYSTEM TYPE 1. PRESSURE ❑ 2. SUCTION ❑ 3. GRAVITY 458 ❑ 1. PRESSURE ❑ 2. SUCTION ❑ 3. GRAVITY 459 CONSTRUCTION ❑ 1. SINGLE WALL ❑ 3. LINED TRENCH ❑ 99. OTHER 460 ❑ 1. SINGLE WALL ❑ 95. UNKNOWN 462 MANUFACTURER ❑K 2. DOUBLE WALL ❑ 95. UNKNOWN ❑ 2. DOUBLE WALL ❑ 99.OTHER MANUFACTURER A.O. Smith 461 MANUFACTURER 463 ❑ 1. BARE STEEL ❑K 6. FRP COMPATIBLE w/100% METHANOL ❑ 1. BARE STEEL ❑ 6. FRP COMPATIBLE W/100% METHANOL ❑ 2. STAINLESS STEEL ❑ 7. GALVANIZED STEEL ❑ Unknown ❑ 2. STAINLESS STEEL ❑ 7. GALVANIZED STEEL ❑ 3. PLASTIC COMPATIBLE W/ CONTENTS ❑ 99. Other ❑ 3. PLASTIC COMPATIBLE W/ CONTENTS ❑ 8. FLEXIBLE (HDPE) 99. OTHER 4. FIBERGLASS ❑ 8. FLEXIBLE (HDPE) ❑ 4. FIBERGLASS ❑ 9. CATHODIC PROTECTION ❑ 5. STEEL W/COATING ❑ 9. CATHODIC PROTECTION 464 ❑ 5. STEEL W/COATING ❑ 95. UNKNOWN 465 I. PIPING LEAK DETECTION (Check all that apply) (A description of the monitoring program shall be submitted to the local agency.) UNDEK6HIJUND I'll'IN6 GROUND 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 ❑ 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 ❑ 2. MONTHLY 0.2 GPH TEST ❑ 3. ANNUAL INTEGRITY TEST (0.1 GPH) ❑ 3. ANNUAL INTEGRITY TEST (0.1GPH) ❑ 4. DAILY VISUAL CHECK CONVENTIONAL SUCTION SYSTEMS CONVENTIONAL SUCTION SYSTEMS (Checkall that apply) 5. DAILY VISUAL MONITORING OF PUMPING SYSTEM +TRIENNIAL PIPING 5. DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM ❑ INTEGRITY TEST (0.1 GPH) SAFE SUCTION SYSTEMS (NO VALUES IN BELOW GROUNDPIPING): ❑ 6. TRIENNIAL INTEGRITY TEST (0.1 GPH) ❑ 7. SELF MONITORING SAFE SUCTION SYSTEMS (NO VALVES IN BELOW GROUND PIPING): GRAVITY FLOW ❑ 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) ❑ 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 11. AUTOMATIC LEAK DETECTOR ❑ OFF OR 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) ❑ 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 ❑ 5. TRENCH LINER/ MONITORING 2006 ❑X 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. � DATE 470 9/27/07 471 NAME OF OWNER/OPRATOR(print) Daniel A Erickson -TlTM-UFUWNEMPtKAIUK 472 Compliance Manager ermit Number tFor local use only) 473 Permit Approved (For local use only) er mt pvation Date or local use only) UPCF (12/99 revised) 12 Formerly SWRCB Form B