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r )uF f,1151o7K UNIFIED PROGRAM (UP) FORM UNDERGROUND STORAGE TANKS - TANK PAGE 2 VI. PIPING CONSTRUCTION (Check all that apply) Page of UNDERGROUND PIPING ABOVEGROUND PIPING SYSTEM TYPE ®1. PRESSURE 0 2. SUCTION 03. GRAVITY 458 ❑ 1. PRESSURE 0 2. SUCTION ❑ 3. GRAVITY 459 CONSTRUCTION ❑ 1. SINGLE WALL O 3. LINED TRENCH 099. OTHER 460 ❑ 1. SINGLE WALL ❑ 95. UNKNOWN 462 MANUFACTURER ® 2. DOUBLE WALL ❑ 95. UNKNOWN ❑ 2. DOUBLE WALL ❑ 99. OTHER MANUFACTURER ENVIRON 461 MANUFACTURER 489 MATERIALS AND EI1 BARE STEEL O 6. FRP COMPATIBLE W/100% 01 BARE STEEL ❑ 6. FRP COMPATIBLE W/100% METHANOL CORROSION METHANOL PROTECTION 0 2, STAINLESS STEEL ❑ 7. GALVANIZED STEEL [195. UNKNOWN [12. STAINLESS STEEL ❑ 7. GALVANIZED STEEL ❑ 3. PLASTIC COMPATIBLE W/ CONTENTS ® 8. FLEXIBLE (HDPE) ❑3. PLASTIC COMPATIBLE ❑ 8. FLEXIBLE (HDPE) El 95. UNKNOWN W/CONTENTS [14. FIBERGLASS ❑ 9. CATHODIC PROTECTION 0 4. FIBERGLASS ❑ 9. CATHODIC PROTECTION ❑ 5. STEEL W/COATING ❑ 99. OTHER 484 1 O 5. STEEL W/COATING ❑ 99. OTHER 465 VII. PIPING LEAK DETECTION (Check all that apply) (A des ai tion of me monitchng program shall be submitted to the localagency.) UNDERGROUND PIPING ABOVEGROUND PIPING SINGLE WALL PIPING 466 SINGLE WALL PIPING 467 PRESSURIZED PIPING (Check all that apply): PRESSURIZED PIPING (Check all that apply): ❑ I. ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP ❑ 1. ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP SHUT OFF FOR LEAK, SYSTEM FAILURE, AND SYSTEM SHUT OFF FOR LEAK, SYSTEM FAILURE, AND SYSTEM DISCONNECTION + AUDIBLE AND VISUAL ALARMS. DISCONNECTION + AUDIBLE AND VISUAL ALARMS. [12. MONTHLY 0.2 GPH TEST ❑ 2. MONTHLY 0.2 GPH TEST ❑ 3. ANNUAL INTEGRITY TEST (0.1GPH) [13. ANNUAL INTEGRITY TEST (0.1 GPH) [34. DAILY VISUAL CHECK CONVENTIONAL SUCTION SYSTEMS (Check all that apply) CONVENTIONAL SUCTION SYSTEMS (Check all that apply) ❑ S. DAILY VISUAL MONITORING OF PUMPING SYSTEM +TRIENNIAL PIPING 0 5. DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM INTEGRITY TEST (0.1 GPH) ❑ 6. TRIENNIAL INTEGRITY TEST (0.1 GPH) SAFE SUCTION SYSTEMS (NO VALUES IN BELOW GROUNDPIPING): SAFE SUCTION SYSTEMS (NO VALVES IN BELOW GROUND PIPING): ❑ 7. SELF MONITORING ❑ 7. SELF MONITORING GRAVITY FLOW GRAVITY FLOW (Check all mat apply): ❑ 9. BIENNIAL INTEGRITY TEST (0.1 GPH) 08. DAILY VISUAL MONITORING 09. BIENNIAL INTEGRITY TEST (0.1 GPH) SECONDARILY CONTAINED PIPING SECONDARILY CONTAINED PIPING PRESSURIZED PIPING (Check all that apply): PRESSURIZED PIPING (Check all that apply): 10. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL 10. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL ALARMS AND (Check one) 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 ❑ b AUTO PUMP SHUT OFF FOR LEAKS, SYSTEM FAILURE AND SYSTEM SYSTEM DISCONNECTION DISCONNECTION [3c. NO AUTO PUMP SHUT OFF Oc NO AUTO PUMP SHUT OFF X11. AUTOMATIC LEAK DETECTOR (3.0 GPH TEST) WITHFLOW SHUT OFF [111. AUTOMATIC LEAK DETECTOR ❑ 12. ANNUAL INTEGRITY TEST (0.1 GPH) (112. ANNUAL INTEGRITY TEST (0.1 GPH) SUCTION/GRAVRY SYSTEM SUCTIOWGRAVITY SYSTEM ❑ 13. CONTINUOUS SUMP SENSOR + AUDIBLE AND VISUAL ALARMS ❑ 13. CONTINUOUS SUMP SENSOR + AUDIBLE AND VISUAL ALARMS EMERGENCY GENERATORS ONLY (Check all that apply) EMERGENCY GENERATORS ONLY (Check all that apply) ❑ 14. CONTINUOUS SUMP SENSOR WITHOl1T AUTO PUMP SHUT OFF [114. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF' AUDIBLE AND VISUAL ALARMS AUDIBLE AND VISUAL ALARMS ❑ 15. AUTOMATIC LEAK DETECTOR (3.0 GPH) WITHOUT FLOW SHUT OFF [115. AUTOMATIC LINE LEAK DETECTOR (3.0 GPH TEST) ❑ 16. ANNUAL INTEGRITY TEST (0.1 GPH) O 17. DAILY VISUAL CHECK ❑ 16. ANNUAL INTEGRITY TEST (0.1 GPH) ❑ 17. DAILY VISUAL CHECK VIII. DISPENSER CONTAINMENT DISPENSER CONTAINMENT ❑ 1. FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE [14. DAILY VISUAL CHECK DATE INSTALLED 468 ❑ 2. CONTINUOUS DISPENSER PAN SENSOR + AUDIBLE AND VISUAL ALARMS ❑ 5. TRENCH LINER / MONITORING ® 3. CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR ❑ 6. NONE 469 1997 DISPENSER + AUDIBLE AND VISUAL ALARMS IX. OWNER/OPERATOR SIGNATURE I certify that the information rovl 0ereIn Is Inm and eccurete to the best of my knowledge. SIGNATURE OF W P TOR • 4rk� DATE 470 NAME OF Opnn TITLE OF OWNER/OPERATOR 472 Cynthia H. Madrid General Manager, Retail Services UP FORM (1/2000 Version) SBC UST-B.doc Formerly SWRCB Form B