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UNIFIED PROGRAM CONSOLIDATED FORM TANKS UNDERGROUND STORAGE TANKS - TANK PAGE 2 Pon. of VI.PIPING CONSTRUCTION(Chack as that appy) UNDERGROUND PIPING ABOVEGROUND PIPING SYSTEM TYPE ❑ 1 PRESSURE ❑ 2. SUCTION 113. GRAVITY L11. PRESSURE ❑ 2. SUCTION ❑ 3. GRAVITY CONSTRUCTION/ 1. SINGLE WALL ❑ 3. LINEDTRENCH ❑89. OTHER ❑ 1. SINGLE WALL ❑M. UNKNOWN MANUFACTURER ❑ 2. DOUBLE WALL ❑95. UNKNOWN ❑ 2. DOUBI-EWALL ❑99. OTHER MANUFACTURERMANUFACTURER 1,BARE STEEL ❑ e. FRP COMPATIBLE W/100%METHANOL ❑ 1. BARE STEEL ❑ 8. FRP COMPATIBLE W1100%METHANOL MATERIALSAND ❑ 2_ STAINLESS STEEL ❑ T. GALVANIZED STEEL ❑ 2. STAINLESS STEEL ❑ T. GALVANIZED STEEL CORROSION PROTECTION ❑ 3. PLASTIC COMPATIBLE WITH CONTENTS ❑95. UNKNOWN ❑ 3. PLASTIC COMPATIBLE WITH CONTENTS ❑ 5. FLEXIBLE(HDPE) ❑99. OTHER ❑ 4. FIBERGLASS ❑ 8. FLEXIBLE(HDPE) 1199 OTHER ❑ 4. FIBERGIASS ❑ 9. CATHODIC PROTECTION ❑ 5. STEEL WICOATING ❑ 9. CATHODIC PROTECTION ❑ 5. STEEL W1 COI 1195 UNKNOWN VII:PIPING LEAK DETECTION(Check all that apply) UNDERGROUND PIPING ABOVEGROUND PIPING SINGLE WALL PIPING SINGLE WALL PIPING PRESSURIZED PIPING(Check all that appy): PRESSURIZED PIPING(Chock all that apply): ❑ 1. ELECTRONIC LINE LEAK DETECTOR 3.0 GPM TEST WITH AUTO PUMP SHUT OFF FOR ❑ 1. ELECTRONIC LINE LEAK DETECTOR 3.0 GPM TEST WITH AUTO PUMP SHUTOFF FOR LEAK, LEAK,SYSTEM FAILURE,AND SYSTEM DISCONNECTION+AUDIBLE AND VISUAL SYSTEM FAILURE,AND SYSTEM DISCONNECTION;-AUDIBLE AND VISUAL ALARMS ALARMS ❑ 2. MONTHLY 0.2GPH TEST ❑ 2. MONTHLY 0.2 GPT TEST ❑ 3.ANNUAL INTEGRITY TEST(0.1 GPM) 113. ANNUAL INTEGRITY TEST(0.1 GPM) ❑ 4. DAILY VISUAL CHECK CONVENTIONAL SUCTION SYSTEMS: CONVENTIONAL SUCTION SYSTEMS(Check all that appy): ❑ S. DAILY VISUAL MONITORING OF PUMPING SYSTEM+TRIENNIAL PIPING INTEGRITY ❑ 5. DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM TEST(0.1 GPM) ❑ e. TRIENNIAL INTEGRITY TEST(0:1 GPM) SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING)'. ❑ T. SELF MONITORING ❑ 7. SELF MONITORING GRAVITY FLOW: GRAVITY FLOW(Check ak that apply): ❑ 9. BIENNIAL INTEGRITY TEST(01 GPM) ❑ B. DAILY VISUAL MONITORING ❑ 9. BIENNIAL INTEGRITY TEST(0.1 GPM) SECONDARILY CONTAINED PIPING SECONDARILY CONTAINED PIPING PRESSURIZED PIPING(Check all that apply): PRESSURIZED PIPING(Check ad fhot apply): 10. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL ALARMS AND DnxA one) 10.CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL ALARMS AND(check one) ❑ e.AUTO PUMP SHUT OFFWHEN A LEAK OCCURS ❑ a. AUTO PUMP SHUTOFFWHEN A LEAKOCCURS ❑ D. AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM ❑ DISCONNECTION b. AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM DISCONNECTION ❑ c NOAUTO PUMP SHUT OFF ❑ a NOAUTO PUMP SHUTOFF ❑ 11.AUTOMATIC LINE LEAK DETECTOR(3.0 GPM TEST)WITH FLOW SHUT OFF OR ❑ 11. AUTOMATIC LEAK DETECTOR RESTRICTION ❑ 12.ANNUAL INTEGRITY TEST(0.1 GPM) ❑ 12. ANNUAL INTEGRITY TEST(0.1 GPM) SUCTIONIGRAVITY SYSTEM: SUCTIOWGRAViT1'SYSTEM'. ❑ 13. CONTINUOUS SUMP SENSOR,AUDIBLE AND VISUAL ALARMS ❑ 13. CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS EMERGENCY GENERATORS ONLY(Check a¢that apply) EMERGENCY GENERATORS ONLY(Chock 09 fhot apply) ❑ 14 CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF+AUDIBLE AND ❑ 14. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF+AUDIBLE AND VISUAL VISUAL ALARMS ALARMS ❑ 15.AUTOMATIC LINE LEAK DETECTOR(3.D GPM TEST)WITHOUT FLOW SHUT OFF OR ❑ 15. AUTOMATIC LINE LEAK DETECTOR(3.0 GPM TEST) RESTRICTION ❑ fe.ANNUAL INTEGRITY TEST(0.1 GPM) ❑ 18.ANNUAL INTEGRITY TEST lot GPM) ❑ 17. DAILY VISUAL CHECK ❑ 17. DAILY VISUAL CHECK 911k:DISPENSER CONTAINMENT DISPENSER CONTAINMENT ❑ 1. FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE ❑ 4. DAILY VISUAL CHECK DATEINSTALIED ❑ 2. CONTINUOUS DISPENSER PAN SENSOR+AUDIBLE AND VISUAL ALARMS ❑ S. TRENCHUNER I MONITORING ❑ 3. CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR DISPENSER+AUDIBLE AND VISUAL ALARMS ❑8. NONE IX OWNER/OPERATOR SIGNATURE I caHiry Val the inmrmaWn P.1ced herein is".and accurate W Na bast of my kooNlea9a. SIGNATURE OF OWNERIOPERATOR DATE NAME OF OWNERtOPERATOR(pont) TITLE OF ONMERIOPERATOR Permit Number(Forha:al pas only) Permit APP.W(For localues oMyf Perm0 a,pabon Date(Forlocel use oMy) CUPAFORM(4/99) • Formerly SWRCB Form B