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UNIFIED PROGRAM CONSOLIDATED FORM TANKS UNDERGROUND STORAGE TANKS - TANK PAGE 2 VL PIPING CONSTRUCTION(Check ea lhafAPPt4 UNDERGROUND PIPING ABOVEGROUND PIPING SYSTEM TYPE ❑ 1 PRESSURE ❑ 2. SUCTION ❑ 3. GRAVITY ❑ 1. PRESSURE ❑ 2. SUCTION ❑ 3. GRAVITY CONSTRUCTIONI ❑ T SINGLE WALL ❑ 3. UNEDTRENCH 1199 OTHER ❑ 1. SINGLE WALL ❑95. UNKNOWN MANUFACTURER ❑ 2 DOUBLE WALL ❑95. UNKNOWN ❑ 2. DOUBLE WALL ❑99. OTHER MANUFACTURER MANUFACTURER ❑ 1 BARE STEEL ❑ 0. FRP COMPATIBLE W/10(Y%METHANOL ❑ 1. BARE STEEL ❑ 0. FRP COMPATIBLE WI 100%METHANOL MATERIALS AND ❑ 2. STAINLESS STEEL 117.GALVANIZED STEEL ❑ 2. STAINLESS STEEL ❑ 7. GALVANIZED STEEL CORROSION ❑ PROTECTION ❑ 3. PLASTICCOMPATIBLEWITH CONTENTS 95 UNKNOWN 113. PLASTIC COMPATIBLE WITH CONTENTS 118. FLE%IBLE(HOPE) Be❑ . OTHER ❑ A. FIBERGLASS ❑ B. FLEXIBLEIHDPE) 11 Be OTHER ❑ L FIBERGLASS ❑ 0. CATHODIC PROTECTION ❑ 5. STEEL WICOATING ❑ S. CATHODIC PROTECTION ❑ 5. STEELW/COATING 095. UNKNOWN VII.PIPING LEAK DETECTION(Check akf of apply) UNDERGROUND PIPING ABOVEGROUND PIPING SINGLE WALL PIPING SINGLE WALL PIPING PRESSURIZED PIPING(Check 0 that apply): PRESSURIZED PIPING(Chick ap Mal apply): ❑ L ELECTRONIC LINE LEAK DETECTOR 3.0 GPM TEST WITH AUTO PUMP SHUT OFF FOR ❑ 1. ELECTRONIC UNE LEAK DETECTOR S0 GPM TEST WITH AUTO PUMP SHUT OFF FOR LEAK, LEAK,SYSTEM FAILUPE,AND SYSTEM DISCONNECTION•AUDIBLE AND VISUAL SYSTEM FAILURE,AND SYSTEM DISCONNECTION a AUDIBLE AND VISUAL ALARMS ALARMS ❑ 2. MONTHLY 0.2 GPM TEST ❑ 2. MONTHLY 02 GPM TEST ❑ 3.ANNUAL INTEGRITY TEST IDA GPM) ❑ 3.ANNUAL INTEGRITY TEST III I GPM) ❑ a. DAILY VISUAL CHECK CONVENTIONAL SUCTION SYSTEMS. CONVENTIONAL SUCTION SYSTEMS(Check all that appy): ❑ 5 DAILY VISUAL MONITORING OF PUMPING SYSTEM.TRIENNIAL PIPING INTEGRITY ❑ 51 DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM TEST III.I GPM) ❑ B. TRIENNIAL INTEGRITY TEST(0 t GPM) SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING) SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING)'. ❑ 7 SELFMONITORING ❑ 7. SELFMONITORING GRAVITY FLOW GRAVITY FLOW(Clack NO Mat apply): ❑ 9. BIENNIAL INTEGRITY TEST R)1 GPM) ❑ B DAILY VISUAL MONITORING ❑ 9 BIENNIAL INTEGRITY TEST(0 1 GPM) SECONDARILY CONTAINED PIPING SECONDARILY CONTAINED PIPING PRESSURIZED PIPING(Check at that apply): PRESSURIZED PIPING(Check ap that appy): 10. CONTINUOUS TURBINE SUMP SENSOR W1TN AUDIBLE AND VISUAL ALARMS AND (Che"one) 10.CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL ALARMS AND(ue"one) ❑ A AUTO PUMP SHUT OFF WHEN A LEAK OCCURS ❑ e.AUTO PUMP SHUT OFF WHEN A LEAK OCCURS ❑ p AUTO PUMP DISCONNECTION SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM DISCONNEC ❑ p, AUTO PUMP SHUTOFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM DISCONNECTION DIS ❑ e. NO AUTO PUMP SHUT OFF ❑ c NO AUTO PUMP SHUT OFF ❑ 11. AUTOMATIC LINE LEAK DETECTOR(00 GPM TEST)WITH FLOW SHUT OFF OR ❑ 11, AUTOMATIC LEAK DETECTOR RESTRICTION ❑ 12. ANNUAL INTEGRITY TEST III I GPM) ❑ 12. ANNUAL INTEGRITY TEST B.1 GPM) SUCTIONIGRAVITY SYSTEM'. SUCTION/GRAVITY SYSTEM: ❑ 13.CONTINUOUS SUMP SENSOR.AUDIBLE AND VISUAL ALARMS ❑ 13 CONTINUOUS SUMP SENSOR.AUDIBLE AND VISUAL ALARMS EMERGENCY GENERATORS ONLY(Check alf that appy) EMERGENCY GENERATORS ONLY(Cha k all Me,apply) ❑ 14. CONTINUMS SUMP SENSOR"THOUTAUTO PUMP SHUT OFF.AUDIBLE AND ❑ 14, CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF a AUDIBLE AND VISUAL VISUALALARMS ALARMS ❑ 15. AUTOMATIC LINE LEAK DETECTOR(3.0 GPM TEST)WITHOUT FLOW SHUT OFF OR ❑ 15. AUTOMATIC LINE LEAK DETECTOR(3.0 GPM TEST) RESTRICTION ❑ 16. ANNUAL INTEGRITY TEST ID.I GPM) ❑ 19. ANNUAL INTEGRITY TEST(a 1 GPM) ❑ 17. DAILY VISUAL CHECK ❑ 17. DAILY VISUAL CHECK VIII.DISPENSER CONTAINMENT DISPENSERCONTAINMENT ❑ 1. FLOAT MECHANISM THAT SHUTS OFF SMEAR VALVE ❑ a. DAILYVISUALCHECK DATEINSTALLED ❑ 2. CONTINUOUS DISPENSER PAN SENSOR+AUDIBLE AND VISUAL ALARMS ❑ 5. TRENCH LINER/MONITORING ❑ 3. CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR DISPENSER a AUDIBLE AND VISUAL ALARMS ❑ S. NONE DL OWNERIOPERATOR SIGNATURE I/arMr Ilial Me information pmvMad herein is MaI and.1.10 Me pest of my WlowledW SIGNATURE OF OWNER/OPERATOR DATE NAME OF OWNER/OPERATOR/p/krp TITLE OF OWNER/OPERATOR Pemel Nt w(For bcal uta oryl Parmil Approved(Frorlecal uea onW PanedEvp.W.Dm fForlacal use oMy) CUPAFORM(4/99) Formerly SWRCB Fonn B � J