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` �a1�h•a. a��c, <br /> oma( 012, <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> TANKS <br /> UNDERGROUND STORAGE TANKS - TANK PAGE 2 <br /> VI.PIPING CONSTRUCTION 4711 kalltlaa I paaez ofZ <br /> UNDERGROUND PIPING ABOVEGROUND PIPING <br /> SYSTEM TYPE 0 L PRESSURE UCI70N 0 3.GRAVITY 458 0 1.PRESSURE 0 2. SUCTION 0 3.GRAVITY 459 <br /> CONSTRUCTION 0 1.SINGLE WALL D 3.LINED TRENCH 0 99.OTHER 469 0 1.SINGLE WALL D 95.UNKNOWN 462 <br /> MANUFACTURER(14,DOUBLE WALL Cl 95.UNKNOWN 0 2.DOUBLE WALL 0 99.OTHER <br /> MANUFACTURER MI MANUFACTURER 463 <br /> O I.BARE STEEL 06.FRP COMPATIBLE wAarA ME7 NM 01.BARE STEEL 06.FRP COMPATIBLE W/IWB MEfBANOL <br /> D 2.STAINLESS STEEL D 7.GALVANIZED STEEL MUNmpwa 0 2. STAINLESS STEEL 0 7.GALVANIZED STEEL <br /> 0 3.PLASTIC COMPATIBLE W/CONTENTS 0 99. Other 0 3. PLASTIC COMPATIBLE W/CONTENTS D 8.FLEXIBLE(HDPE) D 99. OTHER <br /> 0 4.FIBERGLASS 0 8.FLEXIBLE(HDPE) D 4. FIBERGLASS 0 9.CATHODIC PROTECTION <br /> 0 5.STEEL W/COATING ❑9.CATHODIC PROTECTION Ibn ❑5. STEEL W/COATING ❑95.UNKNOWN 165 <br /> VII.PIPING LEAK DETECTION sea at oast I Aaacririea afthe aacani a m awl he mwa .lba <br /> UNDERGROUND PIPING ABOVEGROUND PIPING <br /> SINGLE WALL PIPING 166 SINGLE WALL PIPING 467 <br /> PRESSURIZED PIPING(thea all wt apply): PRESSURIZED PIPING(Check A Nat Wly): <br /> D 1.ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP SHUT 0 1. ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP <br /> OFF FOR LEAK,SYSTEM FAILURE,AND SYSTEM DISCONNECTION+ SHUT OFF FOR LEAK SYSTEM FAILURE,AND SYSTEM DISCONNECTION+ <br /> AUDIBLE AND VISUAL ALARMS. AUDIBLE AND VISUAL ALARMS. <br /> O 2.MONTHLY 0.2 GPH TEST Cl 2. MONTHLY 0.2 GPH TEST <br /> 0 3.ANNUAL INTEGRITY TEST(O.IGPH) D 3.ANNUAL INTEGRITY TEST(O.IGPH) <br /> 0 4. DAILY VISUAL CHECK <br /> CONVENTIONAL SUCTION SYSTEMS CONVENTIONAL SUCTION SYSTEMS(Chink all Wt apply) <br /> 0 5.DAILY VISUAL MONITORING OF PUMPING SYSTEM+TRIENNIAL PIPING <br /> INTEGRITY TEST(0.1 GPH) ❑5. DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM <br /> SAFE SUCTION SYSTEMS(NO VALUES IN BELOW GROUNDPIPING): D 6. TRIENNIAL INTEGRITY TEST(0.1 GPH) <br /> D 7.SELF MONITORING SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): <br /> GRAVITY FLOW D7. SELF MONITORING <br /> 09.BIENNIAL INTEGRITYTEST(O.1GPH) GRAVITY FLOW(ch k all that apply): <br /> 0 8. DAILY VISUAL MONITORING <br /> D 9. BIENNIAL INTEGRITY TEST(0.1 GPH) <br /> SECONDARILY CONTAINED PIPING SECONDARILY CONTAINED PIPING <br /> PRESSURIZED PIPING(Check all thn apply): PRESSURIZED PIPING(Chea all tw apply): <br /> 10. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL 10. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL <br /> ALARMS AND(Check am) ALARMS AND(Check am) <br /> 0 c AUTO PUMP SHUT OFF WHEN A LEAK OCCURS 0 a AUTO PUMP SHUT OFF WHEN A LEAK OCCURS <br /> 0 b. AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM D b AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM <br /> DISCONNECTION DISCONNECTION <br /> De. NO AUTO PUMP SHUT OFF DP NO AUTO PUMP SHUT OFF <br /> 011. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)WITH FLOW SHUT 011 AUTOMATIC LEAK DETECTOR <br /> OFF OR RESTRICTION <br /> 0 12. ANNUAL INTEGRITY TEST(0.1 GPH) D 12. ANNUAL INTEGRITY TEST(0.1 GPH) <br /> SUCTION/GRAVITY SYSTEM SUCTION/GRAVITY SYSTEM <br /> 0,U. CONTINUOUS SUMRSSNSOR+AUDIBLE AND VISUAL ALARMS D 13. CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL-ALARMS <br /> EMERGENCY GENERATORS ONLY(Check all than apply) EMERGENCY GENERATORS ONLY(Check all Ihaa apply) <br /> 0 14. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUTOFF 0 14. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF <br /> AUDIBLE AND VISUAL ALARMS AUDIBLE AND VISUAL ALARMS <br /> 0 15. AUTOMATIC LINE LEAK DETECTOR 0.0 GPH TEST)WITHOUT FLOW 015. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST) <br /> SHUT OFF OR RESTRICTION <br /> 0 16.ANNUAL INTEGRITY TEST(0.1 GPH) 0 16.ANNUAL INTEGRITY TEST(0.1 GPH) <br /> D 17. DAILY VISUAL CHECK D 17. DAILY VISUAL CHECK <br /> VDI.DISPENSER CONTAINMENT <br /> DISPENSER CONTAINMENT 01.FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE 94.DAILY VISUAL CHECK <br /> DATE INSTALLED 468 D 2.CONTINUOUS DISPENSER PAN SENSOR.AUDIBLE AND VISUAL ALARMS D 5.TRENCH LINER/MONITORING <br /> V i\V(4\91w(\ 0 3.CONTINUOUS DISPENSER PAN SENSOR MM AUTO SHUT OFF FOR 0 6.NONE 469 <br /> DISPENSER+AUDIBLE AND VISUAL ALARMS <br /> IX.OWNERIOPERATOR SIGNATURE <br /> Ic fy Meatthe Tafmmatim Pmri4W hems Ewe and acmaaa b the wt army 1'noww9e. <br /> SIGNA�"OF,WOPERAT DATE 4M <br /> l I-ZG-DZ <br /> NAMV, TOR(pmt) Ql TTI'LE OF OWNER/OPERATOR an <br /> D �1A G26U Da I 1G SEL <br /> Pemtit Number(Fm local aae aaly) 473 Permit Awwmv F Baal a,e mly) 474 Pmnit FipitaEoa D.(For local a ae only) 475 <br /> UPCF(12/99 revised) 12 Formerly SWRCB Form B <br />