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I � � UNIFIED PROGRAM CONSOLIDATED FORM TANKS UNDERGROUND STORAGE TANKS - TANK PAGE 2 pa�La z VI.PIPING CONSTRUCTION Check all mate I ABOVEGROUND PIPING UNDERGROUND PIPING 459 SYSTEM TYPE 1.PRESSURE ❑2.SUCTION ❑3.GRAVITY On [11.PRESSURE ❑2. SUCTION [33.GRAVITY 462 CONSTRUCTION ❑1.SINGLE WALL ❑3.LINED TRENCH ❑99.OTHER 450 ❑L SINGLE WALL [195.UNKNOWN ❑2.DOUBLE WALL ❑99.OTHER MANUFAC R A2.DOUBLE WALL [195 UNKNOWN 451 MANUFACTURER 463 MANUFACTURER OW-Ie�.N f"I, ❑6.FRP COMPATIBLE W/IOOXMlmIANOL ❑1.BARE STEEL ❑6.FRP COMPATIBLE aY/100'4 METNAN06 ❑1.BARE STEEL ❑2.STAINLESS STEEL ❑7.GALVANIZED STEEL ❑Un]m°wn ❑2. STAINLESS STEEL [3 7.GALVANIZED STEEL ❑3.PLASTIC COMPATIBLE W/CONTENTS ❑99. Otha ❑3. PLASTIC COMPATIBLE W/CONTENTS [18.FLEXIBLE(HDPE) ❑99. OTHER 4. FIBERGLASS ❑9.CATHODIC PROTECTION �4.FIBERGLASS ❑8.FLEXIBLE(HDPE) C3465 ❑5.STEEL W/COATING ❑9.CATHODIC PROTECTION 454 ❑5. STEEL W/COATING ❑95.UNKNOWN VIL PIPING LEAK DETECTION chat Jl mJa l AMaai � oftaernwitofingpqtuarasna,n x:nland oamme l«Jae«. UNDERGROUND PBING ABOVEGROUND PIPING SINGLE WALL PIPING 455 SINGLE WALL PIPING 067 PRESSURIZED PIPING(Crock all mat applY): PRESSURIZED PIPING(Check all mat apply): ❑1 OFF FOR LEAKLINE SYSTEM DETECTOR 3.0 GpH FAILURE AND SYSTEMSDIS�CO�NNECTION PUNT SHUT ❑1 SHUT O ELECTRONIC FORLEAK SYSM AIOLUREGANDSYSTEM DISCONNECTION PH TEST NIM OPUMP + . AUDIBLE AND VISUAL ALARMS. ADDIBLE AND VISUAL ALARMS ❑ ❑2. MONTHLY 0.2 GPH TEST 2.MONTHLY 0.2 GPH TEST ❑3.ANNUAL INTEGRITY TEST(O.IGPH) ❑3.ANNUAL INTEGRITY TEST(O.1GPH) ❑4. DAILY VISUAL CHECK CONVENTIONAL SUCTION SYSTEMS CONVENTIONAL SUCTION SYSTEMS(Check JI trot RPPIY) ❑5.DAILY VISUAL MONITORING OF PUMPING SYSTEM+TRIENNIAL PIPING ❑S. 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) [17.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(Ch«k JI that apply): ❑S. DAILY VISUAL MONITORING ❑9. BIENNIAL INTEGRITY TEST(0.1 GPH) SECONDARILY CONTAINED PIPING SECONDARILY CONTAINED PIPING PRESSURIZED PIPING(Clark all that RMIY): PRESSURIZED PIPING(Check JI that apply): 10. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL 10. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL ALARMS AND(Chat one) ALARMS AND(Clack o«) ❑a. AUTO PUMP SHUT OFF WHEN A LEAK OCCURS ❑a AUTO PUNT SHUT OFF WHEN A LEAK OCCURS ❑b. AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM ❑b AUTO P SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM DISCONNECTION TION t('c.NO AUTO PUMP SHUT OFF ❑c NO AUTO PUMP SHUT OFF ❑11. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)WITH FLOW SHUT ❑11. AUTOMATIC LEAK DETECTOR OFF OR RESTRICTION 0112. ANNUAL INTEGRITY TEST(0.1 GPH) ❑12. ANNUAL INTEGRITY TEST(0.1 GPH) SUCTION/GRAVITY SYSTEM SUCTION/GRAVITY SYSTEM [113. CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS ❑13. CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS EMERGENCY GENERATORS ONLY(Chat JI mat WIY) EMERGENCY GENERATORS ONLY(Check JI wet apply) ❑14. CONTINUOUS SUMP SENSOR WITH AUTO PUMP SHUT OFF ❑14. CONTINUOUS SUMP SENSOR WITH AUTO PUMP SHUT OFF' AUDIBLE AND VISUAL ALARMS AUDIBLE AND VISUAL ALARMS ❑15. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)WITH 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) [117. DAILY VISUAL CHECK [317. DAILY VISUAL CHECK VDI.DISPENSER CONTAINMENT DISPENSER CONTAINMENT t❑1.FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE ❑4.DAILY VISUAL CHECK DATE INSTALLED 45802,2.CONTINUOUS DISPENSER PAN SENSOR+AUDIBLE AND VISUAL ALARMS ❑S.TRENCH LINER/MONITORING [13.CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR ❑6.NONE 459 DISPENSER+AUDIBLE AND VISUAL ALARMS IX.OWNER/OPERATOR SIGNATURE 1 a fy mat ma inrortnaaon pm.idad herein 4 true and«arena m me l at ortny lumwiMge. SIGNATURE OF OWNER/OPERATOR DATE 479 NAME OF OWNER/OPRATOR(print) 491 1 TITLE OF OWNER/OPERATOR 4R Permit Number(Frrl«J me only) 473 Pemdt Approved(F«10 uaa orgy) 474 Permit ExpiratmR Date(Fm local=rely) 475 UPCF(12/99 revised) 12 Formerly SWRCB Form B