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a <br />( v I) 445(6 -1 R()F &/0/D -,Le <br />UNIFIED PROGRAM (U RM <br />UNDERGROUND STORAGE TANKS - TANK PAGE 2 <br />VI. PIPING CONSTRUCTION (Check all that apply) Page of <br />UNDERGROUND PIPING <br />ABOVEGROUND PIPING <br />SYSTEM TYPE 0 1. PRESSURE 0 2. SUCTION 03. GRAVITY 456 <br />0 1. PRESSURE 0 2. SUCTION 0 3. GRAVITY 459 <br />CONSTRUCTION 0 1. SINGLE WALL 0 3. LINED TRENCH 099. OTHER 460 <br />0 1. SINGLE WALL 0 95. UNKNOWN 462 <br />MANUFACTURER 0 2. DOUBLE WALL 0 95. UNKNOWN <br />0 2. DOUBLE WALL 0 99. OTHER <br />MANUFACTURER ENVIRON 461 <br />MANUFACTURER 463 <br />MATERIALS AND 0 i BARE STEEL 0 6. FRP COMPATIBLE W/100% <br />01 BARE STEEL 0 6. FRP COMPATIBLE W/100% METHANOL <br />CORROSION METHANOL <br />PROTECTION 0 2. STAINLESS STEEL 0 7. GALVANIZED STEEL <br />0 95. UNKNOWN <br />02. STAINLESS STEEL 0 7. GALVANIZED STEEL <br />0 3. PLASTIC COMPATIBLE W/ CONTENTS ® B. FLEXIBLE (HDPE) <br />03. PLASTIC COMPATIBLE O g FLEXIBLE (HDPE) 0 95. UNKNOWN <br />W/CONTENTS <br />0 4. FIBERGLASS 0 9. CATHODIC PROTECTION <br />0 4. FIBERGLASS 0 9. CATHODIC PROTECTION <br />0 5. STEEL W/COATING 0 99. OTHER 464 <br />1 0 5. STEEL W/COATING 0 99. OTHER 465 <br />VII. PIPING LEAK DETECTION (Check all that apply) (A des ai tion of the monitonng program shall be submitted to the local agency.) <br />UNDERGROUND PIPING <br />ABOVEGROUND PIPING <br />SINGLE WALL PIPING 466 <br />SINGLE WALL PIPING 467 <br />PRESSURIZED PIPING (Check all that apply): <br />PRESSURIZED PIPING (Check all that apply): <br />0 1. ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP <br />0 1. ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP <br />SHUT OFF FOR LEAK, SYSTEM FAILURE, AND SYSTEM <br />SHAT OFF FOR LEAK, SYSTEM FAILURE, AND SYSTEM <br />DISCONNECTION + AUDIBLE AND VISUAL ALARMS. <br />DISCONNECTION + AUDIBLE AND VISUAL ALARMS. <br />[12. MONTHLY 0.2 GPH TEST <br />02. MONTHLY 0.2 GPH TEST <br />[13. ANNUAL INTEGRITY TEST (0.1 GPH) <br />[13. ANNUAL INTEGRITY TEST (0.1 GPH) E)4. DAILY VISUAL CHECK <br />CONVENTIONAL SUCTION SYSTEMS (Check all Mat apply) <br />CONVENTIONAL SUCTION SYSTEMS (Check all Mat apply) <br />0 5. DAILY VISUAL MONITORING OF PUMPING SYSTEM + TRIENNIAL PIPING <br />0 5. DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM <br />INTEGRITY TEST (0.1 GPH) <br />❑ 6. TRIENNIAL INTEGRITY TEST (0.1 GPH) <br />SAFE SUCTION SYSTEMS (NO VALUES IN BELOW GROUNDPIPING): <br />SAFE SUCTION SYSTEMS (NO VALVES IN BELOW GROUND PIPING): <br />0 7. SELF MONITORING <br />0 7. SELF MONITORING <br />GRAVITY FLOW <br />GRAVITY FLOW (Check all Mat apply): <br />0 9. BIENNIAL INTEGRITY TEST (0.1 GPH) <br />08. DAILY VISUAL MONITORING 09. BIENNIAL INTEGRITY TEST (0.1 GPH) <br />SECONDARILY CONTAINED PIPING <br />SECONDARILY CONTAINED PIPING <br />PRESSURIZED PIPING (Check all that apply): <br />PRESSURIZED PIPING (Check all that apply): <br />10. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL <br />10. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL <br />ALARMS AND (Check one) <br />ALARMS AND (Check one) <br />❑ a. AUTO PUMP SHUT OFF WHEN A LEAK OCCURS <br />O a AUTO PUMP SHUT OFF WHEN A LEAK OCCURS <br />® b. AUTO PUMP SHUT OFF FOR LEAKS, SYSTEM FAILURE AND <br />0 b AUTO PUMP SHUT OFF FOR LEAKS, SYSTEM FAILURE AND SYSTEM <br />SYSTEM DISCONNECTION <br />DISCONNECTION <br />Oc. NO AUTO PUMP SHUT OFF <br />Oc NO AUTO PUMP SHUT OFF <br />X11. AUTOMATIC LEAK DETECTOR (3.0 GPH TEST) WITHFLOW SHUT OFF <br />0 11. AUTOMATIC LEAK DETECTOR <br />[112. ANNUAL INTEGRITY TEST (0.1 GPH) <br />0 12. ANNUAL INTEGRITY TEST (0.1 GPH) <br />SUCTION/GRAVITY SYSTEM <br />SUCTION/GRAVITY SYSTEM <br />0 13. CONTINUOUS SUMP SENSOR+ AUDIBLE AND VISUAL ALARMS <br />0 13. CONTINUOUS SUMP SENSOR + AUDIBLE AND VISUAL ALARMS <br />EMERGENCY GENERATORS ONLY (Check all Mat apply) <br />EMERGENCY GENERATORS ONLY (Check all that apply) <br />0 14. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF <br />0 14. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF' <br />AUDIBLE AND VISUAL ALARMS <br />AUDIBLE AND VISUAL ALARMS <br />0 15. AUTOMATIC LEAK DETECTOR (3.0 GPH) WITHOUT FLOW SHUT OFF <br />0 15. AUTOMATIC LINE LEAK DETECTOR (3.0 GPH TEST) <br />0 16. ANNUAL INTEGRITY TEST (0.1 GPH) 0 17. DAILY VISUAL CHECK <br />0 16. ANNUAL INTEGRITY TEST (0.1 GPH) [117. DAILY VISUAL CHECK <br />VIII. DISPENSER <br />CONTAINMENT <br />DISPENSER CONTAINMENT <br />❑ 1. FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE 0 4. DAILY VISUAL CHECK <br />DATE INSTALLED 466 <br />❑ 2. CONTINUOUS DISPENSER PAN SENSOR + AUDIBLE AND VISUAL ALARMS 0 5. TRENCH LINER / MONITORING <br />® 3. CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR 0 6. NONE 469 <br />,) 997 <br />DISPENSER + AUDIBLE AND VISUAL ALARMS <br />M. OWNERIOPERATOR SIGNATURE <br />I cenlfy Mat the Infomualon provided herein Is true and accurate to Me beat of my knowledge. <br />SIGNATURE OF OWNE OR , <br />DATE Lf2 3 O } 470 <br />id <br />NAME OFOW n <br />TITLE OF OWNER/OPERATOR 472 <br />Cyn thia . Madrid <br />I General Manager, Retail Services <br />Permit Number <br />UP FORM (1/2000 Version) 3 Formerly SWRCB Form B <br />SBC UST-B.doc <br />