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4 <br /> V <br /> ` UNIFIED PROGRAM CONSOLIDATED FORM <br /> TANKS <br /> UNDERGROUND STORAGE TANKS - TANK PAGE 2 <br /> VI.PIPING CONSTRUCTION nPheek.ii dente I Paas�,.ofL <br /> UNDERGROUND PIPING ABOVEGROUND PIPING <br /> SYSTEM TYPE ALPRESSURE 0 2.SUCTION [13.GRAVITY 458 0 1.PRESSURE 0 2. SUCTION 0 3.GRAVITY 459 <br /> mwsrsUMON 0 1.SINGLE WALL 0 3.LINED TRENCH 0 99.OTHER 460 0 1.SINGLE WALL 0 95.UNKNOWN 463 <br /> MANUFAC R 0 2.DOUBLE WALL 0 95.UNKNOWN 0 2.DOUBLE WALL 0 99.OTHER <br /> MANUFACTURER 461 MANUFACTURER 463 <br /> 0 1.BARE STEEL 0 6.FRP COMPATIBLE w/1WA METHANOL 0 I.BARE STEEL 0 6.FRP COMPATIBLE WA WM METHANOL <br /> [12.STAINLESS STEEL 0 7,GALVANIZED STEEL 0 Und.. 0 2. STAINLESS STEEL 0 7.GALVANIZED STEEL <br /> 0 3.PLASTIC COMPATIBLE W/CONTENTS 0 99. Other 0 3. PLASTIC COMPATIBLE W/CONTENTS 0 8.FLEXIBLE(HDPE) 0 99. OTHER <br /> J,4.FIBERGLASS [18.FLEXIBLE(HDPE) 0 4. FIBERGLASS [19.CATHODIC PROTECTION <br /> 0 5.STEEL W/COATING 0 9.CATHODIC PROTECTION 464 0 S. STEEL W/COATTNG 0 95.UNKNOWN 465 <br /> VII.PIPING LEAK DETECTION(c .11 male 1 Adesvieonofthe..aftanna,rorarn alaell W lamdtted to me loodeenc. <br /> UNDERGROUND PIPING ABOVEGROUND PIPING <br /> SINGLE WALL PIPING 466 SINGLE WALL PIPING 467 <br /> PRESSURIZED PIPING(Cemk all tem apply): PRESSURIZED PIPING(Check all mm apply): <br /> 0 1.ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WrTH AUTO PUMP SHUT 0 1. ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WIC 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 /> 0 2.MONTHLY 0.2 GPH TEST 02. MONTHLY 0.2 GPH TEST <br /> 0 3.ANNUAL INTEGRITY TEST(BIGPH) 0 3.ANNUAL INTEGRITY TEST(O.1GPH) <br /> 0 4. DAILY VISUAL CHECK <br /> CONVENTIONAL SUCTION SYSTEMS CONVENTIONAL SUCTION SYSTEMS(Check dlllw apply) <br /> 0 5.DAILY VISUAL MONITORING OF PUNTING SYSTEM+TRIENNIAL PIPING 0 5. DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM <br /> INTEGRITY TEST(0.1 GPH) <br /> SAFE SUCTION SYSTEMS(NO VALUES IN BELOW GROUNDPIPING): ❑6. TRIENNIAL INTEGRITY TEST(0.1 GPH) <br /> 0 7.SELF MONITORING SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): <br /> GRAVITY FLOW 07. SELF MONITORING <br /> 0 9.BIENNIAL INTEGRITY TEST(0.1 GPH) GRAVITY FLOW(Check dl met apply): <br /> 0 8. DAILY VISUAL MONITORING <br /> 0 9. BIENNIAL INTEGRITY TEST(0.1 GPH) <br /> SECONDARILY CONTAINED PIPING SECONDARILY CONTAINED PIPING <br /> PRESSURIZED PIPING(Check all out apply): PRESSURIZED PIPING(Check dl gw apply): <br /> 10. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL 10. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL <br /> ALARMS AND(Chink one) ALARMS AND(Check ooh) <br /> 0 a. 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 0 b AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM <br /> DISCONNECTION DISCONNECTION <br /> Jac. NO AUTO PUMP SHUT OFF Oc NO AUTO PUMP SHUT OFF <br /> 0 11. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)WI FLOW SHUT 0 it. AUTOMATIC LEAK DETECTOR <br /> OFF OR RESTRICTION <br /> R 12. ANNUAL INTEGRITY TEST(0.1 GPH) 0 12. ANNUAL INTEGRITY TEST(0.1 GPH) <br /> SUCTION/GRAVITY SYSTEM SUCTION/GRAVITY SYSTEM <br /> 013. CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS 013. CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS <br /> EMERGENCY GENERATORS ONLY(Check all tint apply) EMERGENCY GENERATORS ONLY(Check all that apply) <br /> 0 14. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF a 0 14. CONTINUOUS SUMP SENSOR WITH AUTO PUMP SHUT OFF <br /> AUDIBLE AND VISUAL ALARMS AUDIBLE AND VISUAL ALARMS <br /> 0 15. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)WITHOUT FLOW [115. 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 /> [117. DAILY VISUAL CHECK 0 17. DAILY VISUAL CHECK <br /> VOL DISPENSER CONTAINMENT <br /> DISPENSER CONTAINMENT ❑1.FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE 0 4.DAILY VISUAL CHECK <br /> DATE INSTALLED 468 J9 2.CONTINUOUS DISPENSER PAN SENSOR+AUDIBLE AND VISUAL ALARMS ❑S.TRENCH LINER/MONITORING <br /> 0 3.CONTINUOUS DISPENSER PAN SENSOR WIT AUTO SHUT OFF FOR ❑6.NONE 469 <br /> DISPENSER+AUDIBLE AND VISUAL ALARMS <br /> IX.OWNERIOPERATOR SIGNATURE <br /> 1 cm6fy that da,infornn ion provided herein u true earl accmatc to me eel ofmy knowledge. <br /> SIGNATURE OF OWNER/OPERATOR DATE Oro <br /> NAME OF OWNER/OPRATOR(print) 471 1 TITLE OF OWNER/OPERATOR 473 <br /> Pemdt Numeer(Forloaluaeody) 473 Permit Approved(For tread nee only) 474 Petnil Expirarion Wre(For bead uae only) 475 <br /> UPCF(12/99 revised) 12 Formerly SWRCB Form B <br />