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UNIEF ED PROGRAM CONSOLIDATED FORM TANKS UNDERGROUND STORAGE TANKS - TANK PAGE 2 VI.PIPING CONSTRUCTION cjr< an Huta l) UNDERGROUND PIPING ABOVEGROUND PIPING SYSTEM TYPE ®1.PRESSURE [12.SUCTION ❑3.GRAVITY 459 ❑1.PRESSURE [12. SUCTION ❑3.GRAVITY 459 CONSTRUCnON ❑1.SINGLE WALL [13.LINED TRENCH ❑99.OTHER 460 ❑ 1.SINGLE WALL ❑95.UNKNOWN 462 MANUFA="R N 2.DOUBLE WALL ❑95.UNKNOWN ❑2.DOUBLE WALL ❑99.OTHER MANUFACTURER Smith Fiberglass MI MANUFACTURER 46' ❑ 1.BARE STEEL ❑6.FRP COMPATIBLE w/lWt4 METHANOL [11.BARE STEEL Cl 6.FRP COMPATIBLE W11()()%METH 01. ❑2.STAINLESS STEEL ❑7.GALVANIZED STEEL ❑Unmown ❑2. STAINLESS STEEL [17.GALVANIZED STEEL [13.PLASTIC COMPATIBLE W/CONTENTS [199. Odsrr [13. PLASTIC COMPATIBLE W/CONTENTS ❑8.FLEXIBLE(HDPE) ❑99. OTHER ®4.FIBERGLASS ❑B.FLEXIBLE(HDPE) [14. FIBERGLASS [19.CATHODIC PROTECTION [15.STEEL W/COATING ❑9.CATHODIC PROTECTION a64 [15. STEEL W/COATING [195.UNKNOWN 465 V11.PIPING LEAK DETECTION(Check all tWha 1 (Adecription ofthe rnpritering program shall be submitted a the lord UNDERGROUND PIPING ABOVEGROUND PIPING SINGLE WALL PIPING a66 SINGLE WALL PIPING 467 PRESSURIZED PIPING(Check all Naz apply): PRESSURIZED PIPING(Chat ell that appy): ❑ 1.ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITF AUTO PUMP SHUT ❑1. ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST 1vLTU 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 ❑3.ANNUAL INTEGRITY TEST(O.IGPH) ❑3.ANNUAL INTEGRITY TEST(O.IGPH) [14. DAILY VISUAL CHECK CONVENTIONAL SUCTION SYSTEMS CONVENTIONAL SUCTION SYSTEMS(Check all do apply) ❑5.DAILY VISUAL MONITORING OF PUMPING SYSTEM+TRIENNIAL PIPING 0 5. DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM INTEGRITY TEST(0.1 GPH) SAFE SUCTION SYSTEMS(NO VALUES IN BELOW GROUNDPIPING): [16. TRIENNNIAL INTEGRITY TEST(0.1 GPH) ❑7.SELF MONITORING SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): GRAVITY FLOW [3 7. SELF MONITORING [19.BIENNIAL INTEGRITY TEST(0.1 GPH) GRAVITY FLOW(Check all twt appy): [38. DAILY VISUAL MONITORING ❑9. BIENNIAL INTEGRITY TEST(0.1 GPIs) SECONDARILY CONTAINED PIPING SECONDARILY CONTAINED PIPING PRESSURIZED PIPING(Check all thu apply): PRESSURIZED PIPING(Chat all that apply): 10. CONTINUOUS TURBINE SUMP SENSOR WIT AUDIBLE AND VISUAL 10. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL ALARMS AND(Chat aa) ALARMS AND(Chak one) ❑a. AUTO PUMP SHUT OFF WHEN A LEAK OCCURS [3 a AUTO PUMP SHUT OFF WHEN A LEAK OCCURS ®b. AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM ❑It AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM DISCONNECTION DISCONNECTION Oc. NO AUTO PUMP SHUT OFF [3c NO AUTO PUMP SHUT OFF ®11. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)WITH FLOW SHUT 11. AUTOMATIC LEAK DETECTOR OFF OR RESTRICTION ®12. ANNUAL INTEGRITY TEST(0.1 GPH) ❑12. ANNUAL INTEGRITY TEST(0.1 GPH) SUCTION/GRAVITY SYSTEM ' SUCTION/GRAVrrY SYSTEM ❑13. CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS ❑13. CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS EMERGENCY GENERATORS ONLY((Mert all that apply) EMERGENCY GENERATORS ONLY(Check all that apply) ❑14. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF• [114. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF' AUDIBLE AND VISUAL ALARMS AUDIBLE AND VISUAL ALARMS [115. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)WITHOUT FLOW [115. 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 ❑1.FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE ❑4.DAILY VISUAL CHECK DATE INSTALLED 46a [12.CONTINUOUS DISPENSER PAN SENSOR+AUDIBLE AND VISUAL ALARMS ❑5.TRENCH LINER/MONITORING 2003 ®3.CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR 0 6.NONE 469 DISPENSER+AUDIBLE AND VISUAL ALARMS UL OWNERIOPERATOR SIGNATURE I reniH that the information g vidd herein¢true ad accuraze to the beer of my knowledge. SIG E OF OWNER/OPERATOR DATE l A� 470 M, aV N WNER/OPRA OR(pricy 1 4� 471 TITLE OF OWNER/OPERATOR^ 4T7 Permit Number-(For IocN use only)a 1I/ 41C1\.J�4473 Pmnit Approved(For local me only) 14774 Permit Expiration Date(Par local uu only) 475 UPCF(12/99 revised) 12 Formerly SWRCB Form B