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UNIFIED PROGRAM CONSOLIDATED FORM <br /> TANKS <br /> UNDERGROUND STORAGE TANKS - TANK PAGE 2 <br /> VI.PIPING CONSTRUCTION all waz 1 <br /> t]Kck Palle! <br /> ' <br /> UNDERGROUND PIPING ABOVEGROUND PIPING <br /> SYSTEM TYPE 0 1.PRESSURE 0 2.SUCTION 0 3.GRAVITY 458 1 111.PRESSURE 0 2. SUCTION 0 3.GRAVITY 459 <br /> CONSTRUCTION ❑I.SINGLE WALL 0 3.LINED TRENCH 0 99.OTHER 469 0 1.SINGLE WALL 0 95.UNKNOWN 46] <br /> MANUFACTURER ®2.DOUBLE WALL 0 95.UNKNOWN 0 2.DOUBLE WALL 0 99.OTHER <br /> MANUFACTURER Smith Fiberglass MI MANUFACTURER 463 <br /> 0 1.BARE STEEL 0 6.FRP COMPATIBLE W/100% METHANOL 0 1.BARE STEEL 0 6.FRP COMPATIBLE W/l00%METHANOL <br /> 0 2.STAINLESS STEEL 0 7.GALVANIZED STEEL 0 Unknown 0 2. STAINLESS STEEL O 7.GALVANIZED STEEL <br /> 0 3.PLASTIC COMPATIBLE W/CONTENTS 0 99. Other 0 3. PLASTIC COMPATIBLE W/CONTENTS 0 s.FLEXIBLE(HDPE) 0 99. OTHER <br /> 0 4.FIBERGLASS 0 S.FLEXIBLE(ID)PE) 0 4. FIBERGLASS 0 9.CATHODIC PROTECTION <br /> 0 S.STEEL W/COATING 0 9.CATHODIC PROTECTION 464 ❑5. STEEL W/COATING 0 95.UNKNOWN 465 <br /> VII.PIPING LEAKDETECTION Chak an maz I wdevaiptaor.ftlua neottoring propunah.11 beeabruittd an the kul <br /> UNDERGROUND PIPING ABOVEGROUND PIPING <br /> SINGLE WALL PIPING 466 SINGLE WALL PIPING 467 <br /> PRESSURIZED PIPING(Chak all tima apply): PRESSURIZED PIPING(Chak all tled apply): <br /> ❑ 1.ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST W AUTO PUMP SHUT 0 1. ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST NnTf AUTO PUMP <br /> OFF FOR LEAK,SYSTEM FAILURE,AND SYSTEM DISCONNECTION+ SHUT OFF FOR LEAK SYSTEM FAILURE,AND SYSTEM DISCONNECTION+ <br /> AUDIBLE AND VISUAL ALARMS. AUDIBLE AND VISUAL ALARMS. <br /> 0 2.MONTHLY 0.2 GPH TEST 0 2. MONTHLY 0.2 GPH TEST <br /> 0 3.ANNUAL INTEGRITY TEST(O.IGPH) 0 3.ANNUAL INTEGRITY TEST(0.IGPM <br /> 0 4. DAILY VISUAL CHECK <br /> CONVENTIONAL SUCTION SYSTEMS CONVENTIONAL SUCTION SYSTEMS(Check all that apply) <br /> ❑5.DAILY VISUAL MONITORING OF PUMPING SYSTEM+TRIENNIAL PIPING 0 S. DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM <br /> INTEGRITY TEST(0.1 GPH) <br /> SAFE SUCTION SYSTEMS(NO VALUES IN BELOW GROUNDPIPING): 0 6. TRIENNIAL INTEGRITY TEST(0.1 GPM <br /> 0 7.SELF MONITORING SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): <br /> GRAVITY FLOW 07. SELF MONITORING <br /> 0 9.BIENNIAL INTEGRITY TEST(0.1 GPH) GRAVITY FLOW(Check all the apply): <br /> 0 s. DAILY VISUAL MONITORING <br /> 0 9. BIENNIAL INTEGRITY TEST(0.1 GPH) <br /> SECONDARILY CONTAINED PIPING SECONDARILY CONTAINED PIPING <br /> PRESSURIZED PIPING(Check all tha apply): PRESSURIZED PIPING(Cheek all that apply): <br /> 10. CONTINUOUS TURBINE SUMP SENSOR WI AUDIBLE AND VISUAL 10. CONTINUOUS TURBINE SUMP SENSOR WITF3 AUDIBLE AND VISUAL <br /> ALARMS AND(Chak onc) ALARMS AND(Check one) <br /> 0 a. AUTO PUMP SHUT OFF WHEN A LEAK OCCURS 0 a AUTO PUMP SHUT OFF WHEN A LEAK OCCURS <br /> 0 b. AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM 0 b AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM <br /> DISCONNECTION DISCONNECTION <br /> Oc. NO AUTO PUMP SHUT OFF Oc NO AUTO PUMP SHUT OFF <br /> 0 11. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)WITH FLOW SHUT 0 11 AUTOMATIC LEAK DETECTOR <br /> OFF OR RESTRICTION <br /> 0 12. ANNUAL INTEGRITY TEST(0.1 GPH) [112. ANNUAL INTEGRITY TEST(0.1 GPH) <br /> SUCTION/GRAVITY SYSTEM - SUCTION/GRAVITY SYSTEM <br /> ❑13. CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS 0 13. CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS <br /> EMERGENCY GENERATORS ONLY(Chak all ti a Will EMERGENCY GENERATORS ONLY(Check all the apply) <br /> ❑ 14. CONTINUOUS SUMP SENSOR WIT AUTO PUMP SHUT OFF• 0 14. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF <br /> AUDIBLE AND VISUAL ALARMS AUDIBLE AND VISUAL ALARMS <br /> ❑15. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)WITHOUT FLOW 0 15. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST) <br /> SHUT OFF OR RESTRICTION <br /> ❑16.ANNUAL INTEGRITY TEST(0.1 GPH) 0 16.ANNUAL INTEGRITY TEST(0.1 GPH) <br /> 0 17. DAILY VISUAL CHECK [117. DAILY VISUAL CHECK <br /> VIIL DISPENSER CONTAINMENT <br /> DISPENSER CONTAINMENT 0 1.FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE O 4.DAILY VISUAL CHECK <br /> DATE INSTALLED 4611 0 2.CONTINUOUS DISPENSER PAN SENSOR+AUDIBLE AND VISUAL ALARMS 0 5.TRENCH LINER/MONITORING <br /> 2003 0 3.CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR [16.NONE 469 <br /> DISPENSER+AUDIBLE AND VISUAL ALARMS <br /> I7(.OWNER/OPERATOR SIGNATURE <br /> I ccnify Uat Ne infanrntion providd haeme true ad aaunne to Jm bat ofmy koowkdge. <br /> SIGN EOF OWN OP RATO DATE 470 <br /> L Q3 <br /> NAME WNER/OPRA I UK(print) 471 1 TITLE OFOWNER/OPERATOR 7. 4T2 <br /> 7 <br /> Permit Number(For local we only) 473 Perdl Approved(For local we only) 474 Permit Expiration Ua,(For local use only) 475 <br /> UPCF(12/99 revised) 12 Formerly SWRCB Form B <br />