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UNIFIED PROGRAM CONSOLIDATED FORM TANKS UNDERGROUND STORAGE TANKS -TANK PAGE 2 VI.PIPING CONSTRUCTION Chit all that I Page_or UNDERGROUND PIPING ABOVEGROUND PIPING SYSTEM TYPE 0 1.PRESSURE EpiSUCTION 0 3.GRAVITY 458 0 I.PRESSURE 0 2. SUCTION 0 3.GRAVITY 459 cotisnUCITON 0 1.SINGLE WALL 0 3.LINED TRENCH 0 99.OTHER 460 0 I.SINGLE WALL 0 95.UNKNOWN 462 MANIIFACNRERUFSDOUBLE WALL 095.UNKNOWN 02.DOUBLE WALL 099.OTHER MANUFACTURER 461 MANUFACTURER Oct 0 I.BARE STEEL ❑6.FRP COMPATIBLE w/l00% METHANDL 0 1.BARE STEEL 0 6.FRP COMPATIBLE w/190$M6THANot, 0 2.STAINLESS STEEL 0 7.GALVANIZED STEEL Unknown 0 2. STAINLESS STEEL ❑7.GALVANIZED STEEL [13.PLASTIC COMPATIBLE W/CONTENTS [199. Other 0 3. PLASTIC COMPATIBLE W/CONTENTS 0 8.FLEXIBLE(HDPE) 0 99. OTHER 0 4.FIBERGLASS 0 8.FLEXIBLE(HDPE) 0 4. FIBERGLASS 0 9.CATHODIC PROTECTION 0 5.STEEL W/COATING [19.CATHODIC PROTECTION 464 0 5. STEEL W/COATING 0 95.UNKNOWN 465 VII.PIPING LEAK DETECTION Check an 8uta I AdacriP6..fft aaari.g paavaa anal he aalmiioWlo me Iowa UNDERGROUND PIPING ABOVEGROUND PIPING SINGLE WALL PIPING 466 SINGLE WALL PIPING 467 PRESSURIZED PIPING(Check all thatapplyl PRESSURIZED PIPING(check 0 ab+l apply): O 1.ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP SHUT [11. ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST W 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. 0 2.MONTHLY 0.2 GPH TEST [12. MONTHLY 0.2 GPH TEST O 3.ANNUAL INTEGRITY TEST(0.IGPH) 0 3.ANNUAL INTEGRITY TEST(O.IGPH) 0 4. DAILY VISUAL CHECK CONVENTIONAL SUCTION SYSTEMS CONVENTIONAL SUCTION SYSTEMS(Check a0lart apply) ❑5.DAILY VISUAL MONITORING OF PUMPING SYSTEM+TRIENNIAL PIPING O 5. DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM INTEGRITY TEST(0.1 GPH) SAFE SUCTION SYSTEMS(NO VALUES IN BELOW GROUNDPIPING): [16. TRIENNIAL INTEGRITY TEST(0.1 GPH) (17.SELF MONITORING SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): GRAVITY FLOW 07. SELF MONITORING 0 9.BIENNIAL INTEGRITY TEST(0.1 GPH) GRAVITY FLOW(Check all that apply): 0 8. DAILY VISUAL MONITORING 0 9. BIENNIAL INTEGRITY TEST(0.1 GPH) SECONDARILY CONTAINED PIPING SECONDARILY CONTAINED PIPING PRESSURIZED PIPING(Creek all Did apply): PRESSURIZED PIPING(Check all lw apply): 10. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL 10. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL ALARMS AND(Chak one) ALARMS AND((Meck one) 0. AUTO PUMP SHUT OFF WHEN A LEAK OCCURS 0 a AUTO PUMP SHUT OFF WHEN A LEAK OCCURS 0 b. AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM 0 b AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM DISCONNECTION DISCONNECTION Oc. NO AUTO PUMP SHUT OFF Oc NO AUTO PUMP SHUT OFF ❑11. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)JM,QII FLOW SHUT 0 11 AUTOMATIC LEAK DETECTOR OFF OR RESTRICTION O 12. ANNUAL INTEGRITY TEST(0.1 GPH) [112. ANNUAL INTEGRITY TEST(0.1 GPH) SUCTION/GRAVITY SYSTEM SUCTION/GRAVITY SYSTEM p,),3. CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS 013. CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS EMERGENCY GENERATORS ONLY(Check all War apply) EMERGENCY GENERATORS ONLY(Check all ltal apply) ❑14. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF• 0 14. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF AUDIBLE AND VISUAL ALARMS AUDIBLE AND VISUAL ALARMS 0 15. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)WITH FLOW 015. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST) SHUT OFF OR RESTRICTION O 16.ANNUAL INTEGRITY TEST(0.1 GPH) 0 16.ANNUAL INTEGRITY TEST(0.1 GPH) 0 17. DAILY VISUAL CHECK 0 17. DAILY VISUAL CHECK VIII.DISPENSER CONTAINMENT DISPENSER CONTAINMENT 0 1.FLOAT MECHANIST/THAT SHUTS OFF SHEAR VALVE EK.DAILY VISUAL CHECK DATE INSTALLED 46a 0 2.CONTINUOUS DISPENSER PAN SENSOR+AUDIBLE AND VISUAL ALARMS [15.TRENCH LINER/MONITORING V(1w\0w11 0 3.CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR 0 6.NONE 469 DISPENSER+AUDIBLE AND VISUAL ALARMS IX.OWNERIOPERATOR SIGNATURE I eaery thatliauJ tion pmvi bemo icnue aril aceuam b 0x bat ofmy knowledge. SIO RIOPERA R DATE GN Oro I- P14eoPtc, 8e t,26•o2 NA OF OWNER/ RATOR(print) 471 TITLE OF OWNER/OPE OR 472 9� AG G anAc1FIe_ Pewdt Namber(For local urc only) 473 Penni)App aal(For tical uae only) 474 Permit Eapire4w Dade(For bed use aNy) 475 UPCF(12/99 revised) 12 Formerly SWRCB Form B