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m UNIFIED PROGRAM CONSOLIDATED FORM TANKS UNDERGROUND STORAGE TANKS - TANK PAGE 2 VL PIPING CONSTRUCTION fceek.0 thrt 1 P'a EL' UNDERGROUND PIPING ABOVEGROUND PIPING SYSTEM TYPE ®I.PRESSURE ❑2.SUCTION ❑3.GRAVITY 458 ❑1.PRESSURE ❑2. SUCTION ❑3.GRAVITY 459 e0N5TRUCnoN ❑1.SINGLE WALL [33.LINED TRENCH [399.OTHER 460 ❑1.SINGLE WALL ❑95.UNKNOWN 462 MANUFACTURER M 2.DOUBLE WALL ❑95.UNKNOWN ❑2.DOUBLE WALL ❑99.OTHER MANUFACTURER Smith Fiber IRss 461 MANUFACTURER 463 ❑1.BARE STEEL ❑6.FRP COMPATIBLE w/10n% METHANOL 1]1.BARE STEEL ❑6.FRP COMPATIBLE W/IW%METHANOL ❑2.STAINLESS STEEL ❑7.GALVANIZED STEEL ❑Unknown ❑2. STAINLESS STEEL [17.GALVANIZED STEEL ❑3.PLASTIC COMPATIBLE W/CONTENTS ❑99. OOta [13. PLASTIC COMPATIBLE W/CONTENTS ❑8.FLEXIBLE(HDPE) ❑99. OTHER ®4.FIBERGLASS ❑S.FLEXIBLE(HDPE) ❑4. FIBERGLASS [19.CATHODIC PROTECTION ❑5.STEEL W/COATING [19.CATHODIC PROTECTION 461 ❑5. STEEL W/COATING [195.UNKNOWN 465 VII.PIPING LEAK DETECTIONChak ell that Adeacdtion of the rncaimting progaun stalle eubmitted to the Mal em. UNDERGROUND PIPING ABOVEGROUND PIPING SINGLE WALL PIPING 466 SINGLE WALL PIPING 467 PRESSURIZED PIPING(Check all that apply): PRESSURIZED PIPING((Meck all tet apply): ❑1.ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST AUTO PUMP SHUT [11. ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST T 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 [13.ANNUAL INTEGRITY TEST(0.1GPH) ❑3.ANNUAL INTEGRITY TEST(0.1GPH) ❑4. DAILY VISUAL CHECK CONVENTIONAL SUCTION SYSTEMS CONVENTIONAL SUCTION SYSTEMS(Check all that apply) ❑ S.DAILY VISUAL MONITORING OF PUMPING SYSTEM+TRIENNIAL PIPING [15. 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) [17.SELF MONITORING SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): GRAVITY FLOW 07. SELF MONITORING [19.BIENNIAL INTEGRITY TEST(0.1 GPH) GRAVITY FLOW(Chack all that apply): ❑8. DAILY VISUAL MONITORING ❑9. BIENNIAL INTEGRITY TEST(0.1 GPH) SECONDARILY CONTAINED PIPING SECONDARILY CONTAINED PIPING PRESSURIZED PIPING(Ch Jt eat that apply): PRESSURIZED PIPING(Check all that apply): 10. CONTINUOUS TURBINE SUMP SENSOR WIT AUDIBLE AND VISUAL 10. CONTINUOUS TURBINE SUMP SENSOR WIT AUDIBLE AND VISUAL ALARMS AND(Check oppe) ALARMS AND(beck own ❑a AUTO PUMP SHUT OFF WHEN A LEAK OCCURS ❑a AUTO PUMP SHUT OFF WHEN A LEAK OCCURS 19 b. AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM ❑b AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM DISCONNECTION DISCONNECTION (3c: NO AUTO PUMP SHUT OFF (]c NO AUTO PUMP SHUT OFF ®11. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)WIT FLOW SHUT 17 11 AUTOMATIC LEAK DETECTOR OFF OR RESTRICTION ®12. ANNUAL INTEGRITY TEST(0.1 GPH) ❑12. ANNUAL INTEGRITY TEST(0.1 GPI) SUCTION/GRAVITY SYSTEM SUCrION/GRAVITY SYSTEM 013. CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS ❑13. CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS EMERGENCY GENERATORS ONLY(Check all Out apply) EMERGENCY GENERATORS ONLY(Oeck all that apply) ❑14. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF ❑14. CONTINUOUS SUMP SENSOR WITH AUTO PUMP SHUT OFF' AUDIBLE AND VISUAL ALARMS AUDIBLE AND VISUAL ALARMS [115. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)WITHOUT FLOW 0 15. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST) SHUT OFF OR RESTRICTION [116.ANNUAL INTEGRITY TEST(0.1 GPH) ❑16.ANNUAL INTEGRITY TEST(0.1 GPH) [117. DAILY VISUAL CHECK ❑17. DAILY VISUAL CHECK VIII.DISPENSER CONTAINMENT DISPENSER CONTAINMENT [11.FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE ❑4.DAILY VISUAL CHECK DATE INSTALLED 46d ❑2.CONTINUOUS DISPENSER PAN SENSOR+AUDIBLE AND VISUAL ALARMS ❑5.TRENCH LINER/MONITORING 2003 ®3.CONTINUOUS DISPENSER PAN SENSOR WIT AUTO SHUT OFF FOR [16.NONE 469 DISPENSER+AUDIBLE AND VISUAL ALARMS IX.OWNER/OPERATOR SIGNATURE I aeuify that the inforwnian provided hertin is nue and were a to the bat ofmy knowledge. SIGNA OF OWNER/OP RATOR DATi 470 NAM OWNER/OPRATOR(print) 471 1 TITI OF WNER/OPERATOR 4T AtA IM YAAL� i T Pmnit Numlxr(For tical we only) 473 Pened Approved(Por local we only) 474 Permit Expiration Dote(For Ioeal use only) 475 UPCF(12/99 revised) 12 Formerly SWRCB Form B