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D NIFIED PROGRAM CONSOLIDATED FORMni TANKS UNDERGROUND STORAGE TANKS -TANK PAGE 2 VL PIPING CONSTRUCTION((,MCIkad OMfappy) - UNDERGROUND PIPING ASOVEGROUNO PIPING rPROTECTION ❑ t PRESSURE SUCTION ❑ 3. GRAVITY ❑ 1. PRESSURE ❑ 2. SUCTION ❑ 3. GRAVITY NI - SINGLE WALL ❑ 3. LINED TRENCH ❑99. OTHER ❑ 1. SINGLE WALL ❑95. UNKNOWN ER ❑ 2 DOUBLE WALL ❑95. UNKNOWN ❑ 2. DOUBLE WALL ❑99. OTHER MANUFACTURER MANUFACTURER 1.SARESTEEL ❑ 9. FRP COMPATIBLEW/1004 METHANOL ❑ 1. BARE STEEL ❑ G. FRP COMPATIBLE W/100%METHANOL O ❑ 2. STAINLESS STEEL ❑ T. GALVANIZEDSTEEL ❑ 2. STAINLESSSTEEL ❑ T. GALVANIZEDSTEEL ❑ 3. PLASTIC COMPATIBLE WITH CONTENTS ❑95. UNKNOWN ❑ 3. PLASTIC COMPATIBLE WITH CONTENTS ❑ B. FLEXIBLE(HOPE) 099. OTHER ❑ 4. FIBERGLASS ❑ S. FLEKIBLE(HOPE) ON OTHER ❑ 4. FIBERGLASS ❑ B. CATHODIC PROTECTION ❑ S. SMELWICOATING ❑ 9. CATHODICPROTECTION ❑ 5. STEELW/COATING 095. UNKNOWN - 'Al.PIPING LEAK DETECTION(CDmkal iMf appy) UNDERGROUND PIPING ABOVEGROUND PIPING SINGLE WALL PIPING SINGLE WALL PIPING PRESSURIZED PIPING(CMck all that appy): PRESSURIZED PIPING(Check atl Mat appy): ❑ 1. ELECTRONIC LINE LEAK DETECTOR 3.0 GPM TEST WITH AUTO PUMP SHUT OFF FOR ❑ 1. ELECTRONIC UNE LEAK DETECTOR 30 GPM TEST WITH AUTO PUMP SHUT OFF FOR LEAK. LEAK,SYSTEM FAILURE,AND SYSTEM DISCONNECTION+AUDIBLE AND VISUAL SYSTEM FAILURE,AND SYSTEM DISCONNECTION♦AUDIBLE AND VISUAL ALARMS ALARMS ❑ 2. MONTHLY 02 GPM TEST ❑ 2.MONTHLY 0.2 GPH TEST ❑ ]. ANNUAL INTEGRITY TEST(o.i GPM) ❑ 3.ANNUAL INTEGRITY TEST(0.1 GPM) ��I/�q.,� ❑ 4. DAILY VISUAL CHECK CONVENTIONALSUCTIONSYSTEMS: Po //s'✓a 4 CONVENTIONAL SUCTION SYSTEMS(CMck 0 that apply): ❑ 5. DAILY VISUAL MONITORING OF PUMPING SYSTEM+TRIENNIAL PIPING INGR� ❑ S. DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM TEST(0.1 GPM) ❑ B. TRIENNIAL INTEGRITY TEST III.I GPM) SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): ❑ Z. MLFMONITONING ❑ T. SELFMONITORING GRAVITY FLOW GRAVITY FLOW(Cli as fMt appy): ❑ 9. BIENNIAL INTEGRITY MST(0A GPM) ❑ 9. DAILY VISUAL MONITORING ❑ 9. BIENNIAL INTEGRITY TEST IO.I GPM) SECONDARILY CONTAINED PIPING SECONDARILY CONTAINED PIPING PRESSURIZED PIPING(Chi ae that appy): PRESSURIZED PIPING(Check ae Mat appy), 10. CONTINUOUS TURBINE SUMP SENSOR NATM AUDIBLEANDVISUALALARMSAND ICMads CONTINUOUS ane) 10.CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL ALARMS AND(cMackam) ❑ a. AUTO PUMP SMUT OFF WREN A LEAK OCCURS ❑ a.AUTO PUMP SHUT OFF WHEN A LEAK OCCURS ❑ 0 AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM ❑ D. AUTO PUMP SHUT OFF FOR LEAKS.SYSTEM FAILURE AND SYSTEM DISCONNECTION DISCONNECTON ❑ c NO AUTO PUMP SHUT OFF ❑ c NO AUTO PUMP SHUT OFF ❑ 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 III I GPM) SUCTIONIGRAOTY SYSTEM: SUCTION/GMVITY SYSTEM'. ❑ 13.CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS ❑ 13. CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS EMERGENCY GENERATORS ONLY(Check aN that appy) EMERGENCY GENERATORS ONLY(Check as that apply) ❑ 14.CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SMUT OFF+AUDIBLE AND ❑ 14. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF+AUDIBLE AND VISUAL VISUAL ALARMS ALARMS ❑ 15.AUTOMATIC LINE LEAK DETECTOR(00 GPH TEST)WITHOUT FLOW SHUT OFF OR ❑ 15. AUTOMATIC LINE LEAK DETECTOR(3.0 GPM TEST) RESTRICTION ❑ 19.ANNUAL INTEGRITY TEST(0.1 GPM) ❑ 13. ANNUAL INTEGRITY TEST(M 1 GPM) ❑ 17. DAILYVISUAL CHECK ❑ 17 DAILY VISUAL CHECK VHL DISPENSER CONTAINMENT DISPENSER CONTAINMENT ❑ L FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE ❑ 4. DAILYVISUALCHECK DATEINST. ALLEN ❑ 2. CONTINUOUS DISPENSER PAN SENSOR+AUDIBLE AND VISUAL ALARMS ❑ TRENCH LINER/MONITORING 4��LV1cY+1�-/FLIQS:- 03. CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR DISPENSER+AUDIBLE AND VISUAL ALARMS NONE UL OWNER/OPERATOR SIGNATURE I pansy Mal M UKotmawn MdYMad Mannan is Due and a=mts to M Dail of my Knaaledpe SIGNATURE OF OWNERnOPEMTOR DATE NAME OF OWNERKIPERATOR(prMC TIME OF OWNERiOPERATOR Point Nunden(ForbcU Mat pMy) Panmtt Appmvad(lror hcsl uae oNlQ Permi[EapinDon ON(Fwkxal u»oNy) KAO CUPAFORM(4/99) 1 Fomlerly SWRCB Form 6