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UNIFIED PROGRAM CONSOLIDATED FORM TANKS <br /> UNDERGROUND STORAGE TANKS - TANK PAGE 2 <br /> VI.PIPING CONSTRUCTION Chock allthat l Paaeq°fILL <br /> UNDERGROUND PIPING ABOVEGROUND PIPING <br /> SYSTEM TYPE 0 1.PRESSURE [:12.SUCTION 0 3.GRAVITY 458 0 1.PRESSURE ❑2. SUCTION ❑3.GRAVITY 459 <br /> CONS1LUCDON 0 1.SINGLE WALL 0 3.LINED TRENCH 0 99.OTHER 460 ❑L SINGLE WALL O 95.UNKNOWN 462 <br /> MANUFACTURER 0 2.DOUBLE WALL 0 95.UNKNOWN 0 2.DOUBLE WALL [199.OTHER <br /> MANUFACTURER Smith Fiberglass MI MANUFACTURER 163 <br /> ❑!.BARE STEEL 0 6.FRP COMPATIBLE W/100% METHANOL ❑1.BARE STEEL [16.FRP COMPATIBLE W/100%MEfHANOL <br /> 0 2.STAINLESS STEEL [17.GALVANIZED STEEL 0 Unknown ❑2. STAINLESS STEEL [17.GALVANIZED STEEL <br /> 0 3.PLASTIC COMPATIBLE W/CONTENTS [199. Other ❑3. PLASTIC COMPATIBLE W/CONTENTS 0 S.FLEXIBLE(HDPE) 0 99. OTHER <br /> 0 4.FIBERGLASS 0 S.FLEXIBLE(HOPE) 0 4. FIBERGLASS [19.CATHODIC PROTECTION <br /> 0 5.STEEL W/COATING 0 9.CATHODIC PROTECTION 464 0 5. STEEL W/COATING [195.UNKNOWN 465 <br /> VII.PIPING LEAK DETECTION Check all that 1 A mption ofthe trookoring rograw shall be motioned an the bol agency) <br /> UNDERGROUND PIING ABOVEGROUND PIPING <br /> SINGLE WALL PIPING 466 SINGLE WALL PIPING 467 <br /> PRESSURIZED PIPING(Check all dal appy): PRESSURIZED PIPING(Choate all that apply): <br /> ❑1.ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST W AUTO PUMP SHUT 111- ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH 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 [32. MONTHLY 0.2 GPH TEST <br /> [13.ANNUAL INTEGRITY TEST(0.1GPH) 0 3.ANNUAL INTEGRITY TEST(O.1GPH) <br /> 0 4. DAILY VISUAL CHECK <br /> CONVENTIONAL SUCTION SYSTEMS CONVENTIONAL SUCTION SYSTEMS(Check all that apply) <br /> 0 S.DAILY VISUAL MONITORING OF PUMPING SYSTEM+TRIENNW.PIPING O 5. DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM <br /> INTEGRITY TEST(0.1 GPH) <br /> SAFE SUCTION SYSTEMS(NO VALUES IN BELOW GROUNDPIPING): O 6. TRIENNIAL INTEGRITY TEST(0.1 GPH) <br /> [17.SELF MONITORING SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): <br /> GRAVITY FLOW 07. SELF MONITORING <br /> O 9.BIENNIAL INTEGRITY TEST(0.1 GPH) GRAVITY FLOW(Check all that apply): <br /> 0 S. DAILY VISUAL MONITORING <br /> [19. BIENNIAL INTEGRITY TEST(0.1 GPH) <br /> SECONDARILY CONTAINED PIPING SECONDARILY CONTAINED PIPING <br /> PRESSURIZED PIPING(Clack all that apply): PRESSURIZED PIPING(Cluca all that apply): <br /> 10. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL 10. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL <br /> ALARMS AND(Check oro) ALARMS AND(Chock oro) <br /> 0 a. AUTO PUMP SHUT OFF WHEN A LEAK OCCURS 0 a AUTO PUMP SHUT OFF WHEN A LEAK OCCURS <br /> ®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 /> Do. NO AUTO PUMP SHUT OFF 06 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) 0 12. ANNUAL INTEGRITY TEST(0.1 GPH) <br /> SUCION/GRAVTrY SYSTEM SUCTION/GRAVITY SYSTEM <br /> 0 13. CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS [113. CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS <br /> EMERGENCY GENERATORS ONLY(Chale all that apply) EMERGENCY GENERATORS ONLY(Chock all that apply) <br /> [114. CONTN(OUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF• 0 14. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF <br /> AUDIBLE AND VISUAL ALARMS AUDIBLE AND VISUAL ALARMS <br /> 0 15. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)WITHOUT FLOW 0 I5. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST) <br /> SHUT OFF OR RESTRICTION <br /> [316.ANNUAL INTEGRITY TEST(0.1 GPH) [116.ANNUAL INTEGRITY TEST(0.1 GPM <br /> [117. DAILY VISUAL CHECK 0 17. DAILY VISUAL CHECK <br /> VIII.DISPENSER CONTAINMENT <br /> DISPENSER CONTAINMENT 0 1.FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE 0 4.DAILY VISUAL CHECK <br /> DATE INSTALLED 468 [12.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 [36.NONE 4(19 <br /> DISPENSER+AUDIBLE AND VISUAL ALARMS <br /> DL OWNER/OPERATOR SIGNATURE <br /> 1 anify,on the infammion pravidd herein u true ab aa:waw to the bat ofmy knowledge. <br /> SIGN OF O R/ T DATE 470 <br /> 471 TITLE F ER/OPERATOR 4n <br /> NAME Of]¢ W1VER/OPRATf//i[ ) �� ®� , <br /> Pmrit Number(For local.anly) 473 Pam¢Approved(For local we only) 474 Parrot Expiration Date(For local use only) 475 <br /> UPCF(12/99 revised) 12 Formerly SWRCB Form B <br />