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oma., tom( n UNIFIED PROGRAM CONSOLIDATED FORM TANKS UNDERGROUND STORAGE TANKS - TANK PAGE 2 VI.PIPING CONSTRUCTION Chrck aliffia'a,111 _oT UNDERGROUND PIPING ABOVEGROUND PIPING SYSTEM TYPE ❑1.PRESSURE EplSUCTION ❑3.GRAVITY 459 ❑1.PRESSURE ❑2. SUCTION ❑3.GRAVITY 459 CONSTRUCDON ❑1.SINGLE WALL ❑3.LINED TRENCH ❑99.OTHER 660 ❑L SINGLE WALL ❑95.UNKNOWN 462 MANUFACDIRER(DOUBLE WALL O 95.UNKNOWN ❑2.DOUBLE WALL O 99.OTHER MANUFACTURER 461 MANUFACTURER 661 ❑I.BARE STEEL O 6.FRP COMPATIBLE wh W MMT NDL ❑1.BARE STEEL ❑6.FRP COMPATIBLE W/I 9.METHANOL O 2.STAINLESS STEEL ❑7.GALVANIZED STEEL AU k o" ❑2. STAINLESS STEEL ❑7.GALVANIZED STEEL ❑3.PLASTIC COMPATIBLE W/CONTENTS ❑99. Otha ❑3.PLASTIC COMPATIBLE W1 CONTENTS ❑8.FLEXIBLE(HDPE) ❑99. OTHER ❑4.FIBERGLASS ❑8.FLEXIBLE(HDPE) ❑4. FIBERGLASS ❑9.CATHODIC PROTECTION ❑5.STEEL W/COATING Cl 9.CATHODIC PROTECTION 464 ❑5. STEEL W/COATING ❑95.UNKNOWN a65 VIL PIPING LEAK DETECTION Chcckall JW Adecriatiand tha ,Hall be aub.ind w the wel UNDERGROUND PIPING ABOVEGROUND PIPING SINGLE WALL PIPING SINGLE WALL PIPING 467 PRESSURIZED PIPING(ClaaA all that apply): PRESSURIZED PIPING(Cl a0 that apply): ❑L ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP SHUT ❑L ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WIT j[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 D 2. MONTHLY 0.2 GPH TEST ❑3.ANNUAL INTEGRITY TEST(0.1GPM ❑3.ANNUAL INTEGRITY TEST(O.1GPH) ❑4. DAILY VISUAL CHECK CONVENTIONAL SUCTION SYSTEMS CONVENTIONAL SUCTION SYSTEMS(Chock all Jut apply) ❑5.DAILY VISUAL MONITORING OF PUMPING SYSTEM+TRIENNIAL PIPING 5. DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM INTEGRITY TEST(0.1 GPH) SAFE SUCTION SYSTEMS(NO VALUES IN BELOW GROUNDPIPING): ❑6.TRIENNIAL INTEGRITY TEST(0.1 GPH) ❑7.SELF MONITORING SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): GRAVITY FLOW 07. SELF MONITORING ❑9.BIENNIAL INTEGRITY TEST(0.1 GPH) GRAVITY FLOW(Crack all wat apply): ❑8. DAILY VISUAL MONITORING ❑9. BIENNIAL INTEGRITY TEST(0.1 GPH) SECONDARILY CONTAINED PIPING SECONDARILY CONTAINED PIPING PRESSURIZED PIPING(Check all that apply): PRESSURIZED PIPING(Check all Jut apply): 10. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL 10. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL ALARMS AND(Check atu) 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 SYSTEM ❑b AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM DISCONNECTION DISCONNECTION 0, NO AUTO PUMP SHUT OFF Oc NO AUTO PUMP SHUT OFF 0I1. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)WITH FLOW SHUT 011 AUTOMATIC LEAK DETECTOR OFF OR RESTRICTION ❑12. ANNUAL INTEGRITY TEST(0.1 GPH) ❑12. ANNUAL INTEGRITY TEST(0.1 GPH) SUCTION/GRAVITY SYSTEM SUCTION/GRAVITY SYSTEM $kj.3. CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS 013. CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS EMERGENCY GENERATORS ONLY(, kale wt apply) EMERGENCY GENERATORS ONLY(Clack all JWapply) [114. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF• [114. CAONTINUOIBLE�SUMP SENSOR D VISUAL ALARM AUTO PUMP SHUT OFF AUDIBLE AND VISUAL ALARMS ❑15. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)WITHOUT FLOW ❑15 AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST) SHUT OFF OR RESTRICTION ❑16.ANNUAL INTEGRITY TEST(0.1 GPH) [116.ANNUAL INTEGRITY TEST(0.1 GPH) 0 17. DAILY VISUAL CHECK 1 ❑17. DAILY VISUAL CHECK VIII.DISPENSER CONTAINMENT DISPENSER CONTAINMENT O1.FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE CK.DAILY VISUAL CHECK DATE INSTALLED 469 ❑2.CONTINUOUS DISPENSER PAN SENSOR+AUDIBLE AND VISUAL ALARMS ❑5.TRENCH LINER/MONITORING V nt*CIM(\ ❑3.CONTINUOUS DISPENSER PAN SENSOR MM AUTO SHUT OFF FOR 0 6.NONE DISPENSER+AUDIBLE AND VISUAL ALARMS IX.OWNERIOPERATOR SIGNATURE I fy JutJu ulemaJon p A&ai heroinntrve and,mate w Ne bet olmy k wladga. SIGN R/OPERA R DATE 4M�on c(v(� 8� ) r- -oz NAM OF O KATOR(Print) 471 TITLE OF OWNER/OPE OR 4n flGR Pm tNumber(Fmwolu Only) 471 Permit ApgOved(For local u,c aolY) 474 Pmnit Expintion hew(Fm kxul uae,Ny) 475 UPCF(12/99 revised) 12 Formerly SWRCB Form B