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UNIFIED PROGRAM CONSOLIDATED FORM TANKS UNDERGROUND STORAGE TANKS - TANK PAGE 2 VI. PIPING CONSTRUCTION (Check all that appy) UNDERGROUND PIPING ABOVEGROUND PIPING SYSTEM TYPE 1. PRESSURE ❑ 2. SUCTION ❑ 3. GRAVITY ❑ 1. PRESSURE ❑ 2. SUCTION ❑ 3. GRAVITY CONSTRUCTION/ ❑ SINGLE WALL ❑ 3. LINED TRENCH ❑ 99. OTHER ❑ 1. SINGLE WALL ❑ 95. UNKNOWN MANUFACTURER 2, DOUBLE WALL ❑ 95. UNKNOWN ❑ 2. DOUBLE WALL ❑ 99. OTHER MANUFACTURER MANUFACTURER ❑ 1. BARE STEEL 8. FRP COMPATIBLE WI 100% METHANOL ❑ 1. BARE STEEL 136 FRP COMPATIBLE W/ 100% METHANOL MATERIALS AND El 2. STAINLESS STEEL ❑ 7. GALVANIZED STEEL ❑ 2. STAINLESS STEEL ❑ 7 GALVANIZED STEEL CORROSION PROTECTION ❑ 3. PLASTIC COMPATIBLE WITH CONTENTS 1:195. UNKNOWN ❑ 3. PLASTIC COMPATIBLE WITH CONTENTS ❑ 8 FLEXIBLE (HDPE) ❑ 99. OTHER ❑ 4. FIBERGLASS ❑ 8. FLEXIBLE (HDPE) ❑ 99. OTHER ❑ 4. FIBERGLASS ❑ 9. CATHODIC PROTECTION ❑ 5. STEEL W/ COATING ❑ 9. CATHODIC PROTECTION ❑ 5. STEEL W/ COATING 1195. UNKNOWN VII. PIPING LEAK DETECTION (Check a# that apply) UNDERGROUND PIPING ABOVEGROUND PIPING SINGLE WALL PIPING SINGLE WALL PIPING 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 FOR ❑ 1. ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP SHUT OFF FOR LEAK, LEAK, SYSTEM FAILURE. AND SYSTEM DISCONNECTION + AUDIBLE AND VISUAL SYSTEM FAILURE, AND SYSTEM DISCONNECTION ;AUDIBLE AND VISUALALARMS ALARMS ❑ 2. MONTHLY 0.2 GPH TEST 112. 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 + TRIENNIAL PIPING INTEGRITY ❑ S. DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM TEST (0.1 GPH) ❑ 6. TRIENNIAL INTEGRITY TEST (0.1 GPH) SAFE SUCTION SYSTEMS (NO VALVES IN BELOW GROUND PIPING): SAFE SUCTION SYSTEMS (NO VALVES IN BELOW GROUND PIPING): ❑ 7. SELF MONITORING ❑ 7. SELF MONITORING GRAVITY FLOW: GRAVITY FLOW (Check all that apply): ❑ 9. BIENNIAL INTEGRITY TEST (0.1 GPH) ❑ 6. 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 ALARMS AND (Cyack one) 10. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL ALARMS AND (check one) Cy►� AUTO PUMP SHUT OFF WHEN A LEAK OCCURS ❑ a. AUTO PUMP SMUT OFF WHEN A LEAK OCCURS AUTO PUMP SHUT OFF FOR LEAKS. SYSTEM FAILURE AND SYSTEM /// DISCONNECTION 11b. AUTO PUMP SHUT OFF FOR LEAKS, SYSTEM FAILURE AND SYSTEM 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 as that apply) EMERGENCY GENERATORS ONLY (Check aft that apply) ❑ 14. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF + AUDIBLE AND ❑ 14. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF + AUDIBLE AND VISUAL VISUALALARMS ALARMS ❑ 15. AUTOMATIC LINE LEAK DETECTOR (3.0 GPH TEST) WITHOUT FLOW SHUT OFF OR ❑ 15. AUTOMATIC LINE LEAK DETECTOR (3.0 GPH TEST) RESTRICTION ❑ 16. ANNUAL INTEGRITY TEST (0.1 GPH) ❑ 16. ANNUAL INTEGRITY TEST (0.1 GPH) ❑ 17. DAILY VISUAL CHECK ❑ 17. DAILY VISUAL CHECK VUL DISPENSER CONTAINMENT DISPENSER CONTAINMENT/ FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE 114. DAILY VISUAL CHECK -111. DAT I STALLED 2. CONTINUOUS DISPENSER PAN SENSOR +AUDIBLE AND VISUAL ALARMS ❑ 5. TRENCH LINER/ MONITORING ❑ 3. CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR DISPENSER + AUDIBLE AND VISUAL ALARMS ❑ 6. NONE IX. OWNER/OPERATOR SIGNATURE I certify that the information provided herein is true and accurate to the best of my knowledge. SIGNATURE OF OWNER/OPERATOR DATE NAME OF OWNERIOPERATOR (print) TITLE OF OWNER/OPERATOR I Permit Number (For local use only) Permit Approved (For local use only) I Permit Expiration Dale (Forlocal use only) CUPAFORM (4/99) Formerly SWRCB Form B