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UNIFIED PROGRAM (UP) FORM"' <br />l <br />UNDERGROUND STORAGE <br />TANKS - TANK PAGE 2 <br />VI. PIPING CONSTRUCTION (Check all that apply) Page of <br />UNDERGROUND PIPING <br />ABOVEGROUND PIPING <br />SYSTEM TYPE ®1. PRESSURE 0 2. SUCTION 03. GRAVITY <br />458 <br />0 1. PRESSURE D 2. SUCTION 0 3. GRAVITY 459 <br />CONSTRUCTION 0 1. SINGLE WALL 0 3. LINED TRENCH 099. OTHER <br />460 <br />0 1. SINGLE WALL D 95. UNKNOWN 462 <br />MANUFACTURER 0 2. DOUBLE WALL 0 95. UNKNOWN <br />0 2. DOUBLE WALL 0 99. OTHER <br />MANUFACTURER ENVIRON <br />461 <br />MANUFACTURER 453 <br />MATERIALS AND D 1. BARE STEEL 0 6. FRP COMPATIBLE w/l00% <br />CORROSION METHANOL <br />01. BARE STEEL 0 6. FRP COMPATIBLE W1100% METHANOL <br />PROTECTION <br />❑ 95. UNKNOWN D 2, STAINLESS STEEL 0 7. GALVANIZED STEEL <br />02. STAINLESS STEEL D 7. GALVANIZED STEEL <br />0 3. PLASTIC COMPATIBLE W/ CONTENTS 0 8. FLEXIBLE (HDPE) <br />03. PLASTIC COMPATIBLE <br />8. 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 D 99. OTHER 464 1 <br />0 5. STEEL W/COATING 0 99. OTHER 465 <br />VII. PIPING LEAK DETECTION (Check all that apply) (Ad ption of the monlUxing 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 />❑ 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 />SHUT OFF FOR LEAK, SYSTEM FAILURE, AND SYSTEM <br />DISCONNECTION + AUDIBLE AND VISUAL ALARMS. <br />DISCONNECTION + AUDIBLE AND VISUAL ALARMS. <br />D 2. MONTHLY 0.2 GPH TEST <br />02. MONTHLY 0.2 GPH TEST <br />0 3. ANNUAL INTEGRITY TEST (0.1 GPH) <br />0 3. ANNUAL INTEGRITY TEST (OAGPH) 04. DAILY VISUAL CHECK <br />CONVENTIONAL SUCTION SYSTEMS (Check all that apply) <br />CONVENTIONAL SUCTION SYSTEMS (Check all mat apply) <br />D 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 />D 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 that apply): <br />0 9. BIENNIAL INTEGRITY TEST (0.1 GPH) <br />D8. 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 (Chock all that apply): <br />10. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL <br />10. CONTINUOUS TURBINE SUMP SENSOR }yUH AUDIBLE AND VISUAL <br />ALARMS AND (Check one) <br />ALARMS AND (Check one) <br />0 a. AUTO PUMP SHUT OFF WHEN A LEAK OCCURS <br />0 a AUTO PUMP SHUT OFF WHEN A LEAK OCCURS <br />0 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 />Dc NO AUTO PUMP SHUT OFF <br />tit. AUTOMATIC LEAK DETECTOR (3.0 GPH TEST) WITHFLOW SHUT OFF <br />D 11. AUTOMATIC LEAK DETECTOR <br />12. ANNUAL INTEGRITY TEST (0.1 GPH) <br />0 12. ANNUAL INTEGRITY TEST (0.1 GPH) <br />SUCTION/GRAVITY SYSTEM <br />SUCTION/GRAVITY SYSTEM <br />013. CONTINUOUS SUMP SENSOR+ AUDIBLE AND VISUAL ALARMS <br />013. CONTINUOUS SUMP SENSOR + AUDIBLE AND VISUAL ALARMS <br />EMERGENCY GENERATORS ONLY (Check all that 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 />015. 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) D 17. DAILY VISUAL CHECK <br />VIII. DISPENSER CONTAINMENT <br />DISPENSER CONTAINMENT <br />0 1. FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE 0 4. DAILY VISUAL CHECK <br />DATE INSTALLED 468 <br />0 2. CONTINUOUS DISPENSER PAN SENSOR + AUDIBLE AND VISUAL ALARMS 0 5. TRENCH LINER / MONITORING <br />0 3. CONTINUOUS DISPENSER PAN SENSOR MM AUTO SHUT OFF FOR [16. NONE 469 <br />1997 <br />DISPENSER+ AUDIBLE AND VISUAL ALARMS <br />IX. OWNER/OPERATOR SIGNATURE <br />I certify mat the informal!grain Is true an cmrate t the best of my knox/edge. <br />zxl <br />SIGNATURE OF 0 RAT <br />DATE 470 <br />NAME OF N R/OPRATOR (print) <br />TITLE OF OWNER/OPERATOR 472 <br />Cynthia H. Madrid <br />I General Manager, Retail Services <br />OFFICIAL USE ONLY Permit Number 473 1 Permit Approved 77" - <br />Expiration Date 475 <br />UP FORM (1/2000 Version) 3 Formerly SWRCB Form B <br />SBC UST-B.doc <br />