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j..r UNIFIED PROGRAM CONSOLIDATED FORM T/, ( - ANKS UNDERGROUND STORAGE TANKS - TANK PAGE 2 b" VI.PIPING CONSTRUCTION(Checka9 Wt apply) UNDERGROUND PIPING ABOVEGROUND PIPING rPROTECnON ❑ ESSURE 2. SUCTION ❑ 3. GRAVITY ❑ 1. PRESSURE ❑ 2. SUCTION 10173. GRA TY N/ 1. SINGLE WALL ❑ 3. LINED TRENCH 1199. OTHER ❑ 1 SINGLE WALL ❑95. UNKNOWN /T\ R ❑ 2. DOUBLE WALL ❑95. UNKNOWN ❑ 2. DOUBLE WALL ❑89. OTHER MANUF CTURER MANUFACTURER ET-1,BARE STEEL ❑ 8. FRP COMPATIBLE WI 100%METHANOL ❑ 1. BARE STEEL ❑ 8. FRP COMPATIBLE W/100%METHANOL D ❑ 2. STAINLESS STEEL ❑ T. GALVANIZEDSTEEL ❑ 2. STAINLESS STEEL ❑ T.GALVANIZED STEEL ❑ 3. PLASTIC COMPATIBLE WITH CONTENTS 0 9. UNKNOWN ❑ 3. PLASTIC COMPATIBLE NTH CONTENTS ❑ B. FLEXIBLE(HDPE) 099. OTHER ❑ C FIBERGLASS ❑ B. FLEXIBLE(HDPE) 0 9. OTHER ❑ 4. FIBERGLASS ❑ 8. CATHODIC PROTECTION ❑ 5. STEELW/COATING ❑ 9. CATHODIC PROTECTION 10 5. STEELW/COATING 095. UNKNOWN VII.PIPING LEAI(DETECTION(CAMck ATMaf appy) UNDERGROUND PIPING __- _ _ _ _ _ _ _ - ABOVEGROUND PIPING - _ -..-- - - -- SINGLE WALL PIPING PRESSURIZED PIPING(Check 0 that apply) PRESSURIZED PIPING(Check 0Maf apply):SINGLE WALL PIPING ❑ 1. ELECTRONIC UNE LEAK DETECTOR 3.0 GPM TEST WITH AUTO PUMP SHUT OFF FOR ❑ 1. ELECTRONIC LINE LEAK DETECTOR BO GPM TEST WITH AUTO PUMP SHUT OFF FOR LEAN. LEAK,SYSTEM FAILURE.AND SYSTEM DISCONNECTION�A ISLE AND VISUAL SYSTEM FAILURE,AND SYSTEM DISCONNECTION;AUDIBLE AND VISUAL ALARMS ALARMS ❑ Z. MONTHLY 0.2 GPM TEST ❑ 2 MONTHLY 0.2 GPH TEST //////��W��1 ❑ 3.ANNUAL INTEGRITY TEST III 1 GPM) ❑ 3. ANNUAL INTEGRITY TEST 10.1 GPM) / / 1/ ❑ 4, DAILY VISUAL CHECK CONVENTIONAL SUCTION SYSTEMS-. /-1 y//I� CONVENTIONAL SUCTION SYSTEMS(Clud W that apPM' ❑ 5 DAILY VISUAL MONITORING OF PUMPING SYSTFM-TRIENNIAL PIPING INTEGRITY ❑ 5. DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM TEST 101 GPM) ❑ B TRIENNIAL INTEGRITY TEST 10.1 GPM) SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING). ❑ i. SELF MONITORING ❑ T. SELF MONITORING GRAVITY FLOW GRAVITY FLOW(Check all that apply): ❑ 9 BIENNIAL INTEGRITY TEST I0.I GPM) a ❑ 8. WILY VISUAL MONITORING ❑ 9 BIENNIAL INTEGRITY TEST(O.I GPM) SECONDARILY CONTAINED PIPING SECONDARILY CONTAINED PIPING PRESSURIZED PIPING(ChecA as that appy): /��/ PRESSURIZED PIPING(Check a8 that apply); 10 OONTINUOUSTURBINE SUMP SENSOR WTTHA IB LE AND VISUAL ALARMS AND ICOad ona) 10.CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL ALARMS AND(chad one) ❑ A AUTO PUMP SHUT OFF WHEN A LEAK OCCURS ❑ e. AUTO PUMP SHUT OFF WHEN A LEAK OCCURS ❑ > AUTO PUMP OFF FOR LEAKS.SYSTEM FAILURE AND DISCONNECTIONECTION ❑ b AUTO PUMP SHUTOFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM DISCONNECTION ❑ c NO AUTO PUMP SHUT OFF ❑ c NO AUTO PUMP SMUT OFF ❑ 11 AUTOMATIC LINE LEAK DETECTOR(3.0 GPM TEST)WITH FLOW SHUT OFF OR ❑ RESTRICTION 11 AUTOMATIC LEAK DETECTOR ❑ 12. ANNUAL INTEGRITY TEST(0 1 GPM) e ❑ 12. ANNUAL INTEGRITY TEST to I GPM) SULTIONIGRAVITY SYSTEM' SUCTIONIGRAVITY SYSTEM: ❑ 13. CONTINUOUS SUMP SENSOR•AUDIBLE AND VISUALALARMS ❑ 13 CONTINUOUS SUMP SENSOR.AUDIBLE AND VISUAL ALARMS EMERGENCY GENERATORS ONLT.(CAskeeHMNppyJ _ , - SDRLRgD y� -- ❑ 14. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF.AUDIBLE AND ❑ 14. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF.AUDIBLE AND VISUAL VISUAL ALARMS ALARMS ❑ 15 AUTOMATIC LINE LEAK DETECTOR(SD GPM TEST)WITHOUT FLOW SHUT OFF OR ❑ 15. AUTOMATIC UNE LEAK DETECTOR(3.0 GPH TEST) RESTRICTION ❑ 18. ANNUAL INTEGRITY TEST III I GPM) ❑ 18 ANNUAL INTEGRITY TEST III I GPM) ❑ 11. DAILY VISUAL CHECK ❑ 1T. WILY VISUAL CHECK VHA.DISPENSER CONTAINMENT DISPENSER CONTAINMENT ❑ 1. FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE ,, //' ❑ 4, WILY VISUAL CHECK DATE INSTALLED ❑2. CONTINUOUS DISPENSER PAN SENSOR-AUDIBLE AND VISUAL ALARMS �./ 2 ❑ 5. TRENCH LINER/MONITORING ❑ 3. CONTINUOUS DISPENSER PAN SENSOR WITH AUTOSHUT OFF FOR DISPENSER• D L/AND VISUAL ALARMS ❑B. NONE BL OWNER/OPERATOR SIGNATURE I[ruN MM Me iNprmabon phlYd"herein Is d A 1 b t o weE9e. SIGNATURE OF ONM ERA DATE y A NAMEOFOW4ERACCERAT TITLE OF OVMEIUOPERATOR Pumii NUMber(Fwbcal ua1 pMy) Pem9t Appgve4(FwhIW use oMA9 ppnR Eapbativn om(FwbW use aaw CUPAFORM(4/99) Fommarly SWRCB Form 5