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4 • I I UNIFIED PROGRAM (UP) FORM UNDERGROUND STORAGE TANKS - TANK PAGE 2 VI. PIPING CONSTRUCTION Check all that a I Page of UNDERGROUND PIPING ABOVEGROUND PIPING SYSTEM TYPE ❑1.PRESSURE 2.SUCTION ❑3.GRAVITY 458 ❑1.PRESSURE 2. SUCTION ❑3.GRAVITY 459 CONSTRUCTION��❑vvvyyy1,,,.SINGLE WALL ❑3.LINED TRENCH (399.OTHER 460 1.SINGLE WALL ❑95.UNKNOWN 462 MANUFACTURERQ.DOUBLE WALL ❑95.UNKNOWN 2.DOUBLE WALL ❑99.OTHER MANUFACTURER _ 461 MANUFACTURER_ 463 MATERIALS AND ❑1 BARE STEEL ❑5.FRP COMPATIBLE w/t00% x1'1 BARE STEEL ❑S.FRP COMPATIBLE wnoox METHANOL CORROSION METHANOL 1'i PROTECTION [3 95.UNKNOWN E32,STAINLESS STEEL ❑7.GALVANIZED STEEL 02.STAINLESS STEEL ❑7.GALVANIZED STEEL ❑3.PLASTIC COMPATIBLE W/CONTENTS ❑e.FLEXIBLE(HDPE) 03.PLASTIC COMPATIBLE W/CONTENTS E36 FLEXIBLE(HDPE)E395.UNKNOWN P1,4.FIBERGLASS ❑9.CATHODIC PROTECTION ❑4. FIBERGLASS ❑9.CATHODIC PROTECTION [15.STEEEL W/COATING ❑99.OTHER_ 464 ❑5. STEEL W/COATING ❑99. OTHER_ 465 VII.PIPING LEAK DETECTION Check all that apply) A de cription of the monitoring ram shall be submitted to the local agency.) UNDERGROUND PIPING ABOVEGROUND PIPING SINGLE WALL PIPING 466 SINGLE WALL PIPING 467 PRESSURIZED PIPING(Check all that appy): PRESSURIZED PIPING(Check all that appy): ❑1.ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP ❑1. ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP SHUT OFF FOR LEAK,SYSTEM FAILURE,AND SYSTEM SHUT OFF FOR LEAK,SYSTEM FAILURE,AND SYSTEM DISCONNECTION+AUDIBLE AND VISUAL ALARMS. DISCONNECTION+AUDIBLE AND VISUAL ALARMS. ❑2.MONTHLY 0.2 GPH TEST ❑2. MONTHLY 0.2 GPH TEST ❑3.ANNUAL INTEGRITY TEST(O.1 GPH) D 3.ANNUAL INTEGRITY TEST(0.1GPH) *4. DAILY VISUAL CHECK CONVENTIONAL SUCTION SYSTEMS(Check all Mat appy) CONVENTIONAL SUCTION SYSTEMS(Check all that appy) ❑5.DAILY VISUAL MONITORING OF PUMPING SYSTEM+TRIENNIAL PIPING INTEGRITY TEST(0.1 GPH) 'SLS. DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM T� ❑6. TRIENNIAL INTEGRITY TEST(0.1 GPH) SAFE SUCTION SYSTEMS(NO VALUES IN BELOW GROUNDPIPING): SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): ❑7:SELF MONITORING ❑7. SELF MONITORING GRAVITY FLOW GRAVITY FLOW(Chao am that appy): ❑9.BIENNIAL INTEGRITY TEST(0.1 GPH) NS.DAILY VISUAL MONITORING ❑9.BIENNIAL INTEGRITY TEST(0.1 GPH) SECONDARILY CONTAINED PIPING SECONDARILY CONTAINED PIPING PRESSURIZED PIPING(Check au that appy): PRESSURIZED PIPING(Check all that appy): 10. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL 10. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL ALARMS AND(Check one) ALARMS AND(Check one) ❑a. AUTO PUMP SHUT OFF WHEN A LEAK OCCURS ❑a AUTO PUMP SHUT OFF WHEN A LEAK OCCURS ❑b. AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND ❑It AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM SYSTEM DISCONNECTION DISCONNECTION .44 )4c. NO AUTO PUMP SHUT OFF ❑c NO AUTO PUMP SHUT OFF .d 11. AUTOMATIC LEAK DETECTOR(3.0 GPH TEST) WITHFLOW SHUT OFF ❑11. AUTOMATIC LEAK DETECTOR ❑ 12 ANNUAL INTEGRITY TEST(0.1.GPH) ❑12. ANNUAL INTEGRITY TEST(0.1 GPH) SUCTION/GRAVITY SYSTEM SUCTION/GRAVITY SYSTEM 3. CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS ❑13. CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS EMERGENCY GENERATORS ONLY(Check all that appy) EMERGENCY GENERATORS ONLY(Check all mat appy) 14. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF 14. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF AUDIBLE AND VISUAL ALARMS rAUDIBLE AND VISUAL ALARMS ❑ 15. AUTOMATIC LEAK DETECTOR(3.0 GPH)WITHOUT FLOW SHUT OFF ❑15. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST) ❑ 16.ANNUAL INTEGRITY TEST(0.1 GPH) ❑17. DAILY VISUAL CHECK ❑16.ANNUAL INTEGRITY TEST(0.1 GPH) Xi7. DAILY VISUAL CHECK VIII. DISPENSER CONTAINMENT DISPENSER CONTAINMENT ❑1.FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE ❑4.DAILY VISUAL CHECK DATE INSTALLED 466 'K2.CONTINUOUS DISPENSER PAN SENSOR+AUDIBLE AND VISUAL ALARMS ❑5.TRENCH LINER/MONITORING r--`-2 �C f ❑3.CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR DISPENSER+AUDIBLE AND VISUAL ALARMS [10.NONE 469 IX. OWNER/OPERATOR SIGNATURE I cartity hat the inrwmalion provided herein Is We and amrale W the cast of my knowledge. SIGNATURE OF O EW �ERgTp yJ DATE 470 NAME OF OWNER/OP OR(pdn0 TITLE OF OWNER/OPERATOR, 472 lye., OFFICIAL USE ONLY Permit Number 473 1 Permit Approved 474 Permit Ezpira0on Date 475 UP Forth(1/2000 Full Version) 33