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low UNIFIED PROGRAM CONSOLIDATED FORM TANKS UNDERGROUND STORAGE TANKS - TANK PAGE 2 Pena ?f VL PIPING CONSTRUCTION:(Cacka m appy, t� ' a'nX.cb `ROUNO UNDERGROUND PIPING A6pVEGROUND PIPING SYSTEM TYPE 1ESSURE ❑ 2.SUCTION ❑ 3. GRAVITY 111. PRESSURE ❑ 2.SUCTION ❑ 3. GRAVITY CONSTRUCT)OW 1. SINGLE WALL ❑ 3. LINEDTRENCH 1199. OTHER ❑ 1.SINGLE WALL 1195. UNKNOWN MANUFACTURER ❑ 2. DOUBLE WALL ❑95. UN ❑ 2. DOUBLE WALL 1199. OTHER MANUFACTURER _61S.4MANUFACTURER " ❑ tBARE STEEL ❑ 8.FRP COMPATIBLE Wl 100%METHANOL ❑ 1. BARE STEEL ❑ e.FRPOOMPATIBLEWI 1W%METHANOL MATERIALS AND ❑ 2. STAINLESSSTEEL ❑ T.GALVANIZEDSTEEL ❑ 2.STAINLESS STEEL ❑T.GALVANIZEDSTEEL CORROSION PROTECTION ❑ 3. PLASTIC COMPATIBLE WITH CONTENTS ❑95. UNKNOWN ❑ 3. PLASTIC COMPATIBLE WITH CONTENTS ❑ B. FLEWBLE(HOPE) ❑99.OTHER ❑ 4. RSERGLASS ❑ S. FLEXIBLE(HDPE) E;4r OTHER ❑4. FIBERGLASS ❑ 9.CATHODIC PROTECTION - - ❑ 5. STEEL W/COATING ❑ 9.CATHODIC PROTECTION 1 ❑ 5. STEEL W/COATING ❑95. UNKNOWN - VII.PIPING LEAK DETECTION(Check a8 that appy] UNDERGROUND PI PING ABOVEGROUND PIPING SINGLE WALL PIPING SINGLE WALL PIPING PRES RIZED PIPING(Checkaethatapply): - PRESSURIZED PIPING(Ch kaB that appy): ELECTRONIC LINE LEAK DETECTOR 3.0 GPM TESTWITH AUTO PUMP SHUT OFF FOR ❑ 1. ELECTRONIC LINE LEAK DETECTOR 3.0 GPM TEST WITH AUTO PUMP SHUT OFF FOR LEAK, LEAK,SYSTEM FAILURE.AND SYSTEM DISCONNECTIONAUDIBLE AND VISUAL SYSTEM FAILURE,AND SYSTEM DISCONNECTION+AUDIBLE AND VISUAL ALARMS ALARMS ❑ 2. MONTHLY 0.2 GPM TEST ❑ 2.ANNALINTEG INTEGRITY TESEST ❑ 3.ANNUAL INTEGRITY TEST(o.1 GPH) ❑ J.ANNVALINTEGRITY TEST(0.1 GPM) ❑ 4. DAILYVISUALCHECK CONVENTIONAL SUCTION SYSTEMS: CONVENTIONAL SUCTION SYSTEMS(Check all that epply l: ❑ S. DAILY VISUAL MONITORING OF PUMPING SYSTEM+TRIENNIAL PIPING INTEGRITY ❑ S. DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM TEST(0.1 GPM) ❑ S.TRIENNIAL INTEGRITY TEST(0.1 GPM) SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): ❑ T. SELF MONITORING ❑ T. SELF MONITORING GRAVITY FLOW: GRAVITY FLOW(Check all that appy): ❑ S. BIENNIAL INTEGRITY TEST(0.1 GPM) - ❑ 8. DAILY VISUAL MONITORING ❑ S. BIENNIALINTEGRITYTEST(OAGPH) -- SECONDARILY CONTAINED PIPING SECONDARILY CONTAINED PIPING PRESSURIZED PIPING(Check all fhaf apply): PRESSURIZED PIPING(Check a6 that apply): 10.CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL ALARMS AND �Clytk one) 10.CONTINUOUS TURBINE SUMP SENSOR WTH AUDIBLE AND VISUAL ALARMS AND(Neck one) MDA UTO PUMP SHUT OFF WHEN A LEAK OCCURS ❑ a.AUTO PUMP SHIT OFF WHEN A LEAK OCCURS AUTO PUMP SHUT OFF FOR LEAKS.SYSTEM FAILURE AND SYSTEM - DISCONNECTION ❑ b.AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM DISCONNECTION /O a NO AUTO PUMP SHUT OFF 11c NO AUTO PUMP SHUT OFF RESTRICTION `❑' 11. NO LINE LEAK DETECTOR(3.0 GPM TEST)WITH FLOW SHUT OFF OR ❑ 11.AUTOMATIC LEAK DETECTOR ❑ 12.ANNUAL INTEGRITY TEST(0.1 GPM) ❑ 12.ANNUAL INTEGRITY TEST(0.1 GPM) SUCTION/GRAVITY SYSTEM: SUCTIONIGRAMTY SYSTEM: - ❑ 13.CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS ❑ 13.CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS EMERGENCY GENERATORS ONLY(Chec atat apply) EMERGENCY GENERATORS ONLY(Cock aN that applA ❑ 14.CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF+AUDIBLE AND ❑ 14.CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF+.AUDIBLE AND VISUAL VISUALALARMS ALARMS ❑ 15. AUTOMATIC UNE LEAK DETECTOR(3.0 GPM TEST)WITHOUT FLOWSHUT OFF OR ❑ 15.AUTOMATIC LINE LEAK DETECTOR(3.0 GPM TEST) RESTRICTION ❑ 18.ANNUAL INTEGRITY TEST(0.1 GPM) ❑ 18. ANNUAL INTEGRITYTEST(0.1 GPM) ❑ 17. DAILY VISUAL CHECK - ❑ 17. DAILY VISUAL CHECK S VIIL DISPENSER CONTAINMENT'y DISPENSER CONTAINMENT ❑ 1. FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE ❑ 4. DAILY VISUAL CHECK DATE INSTALLED ❑ 2. WINUOUS DISPENSER PAN SENSOR+AUDIBLE AND MSUALALARMS ❑ S.TRENCH LINER/MONITORING =NINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR DISPENSER+AUDIBLE AND VISUAL ALARMS ❑ S. NONE DL OWNERIOPERATOR SIGNATURE I cemiy that Ne information pmvided hemi,,is We and aoamle W Me beat of my kmpWedya. SIGNATUREOFOVJNER/OPERATOR DATE NAME OF OWNERIOPERATOR(pNry TTTLEOFONMERIOPERATOR - Petmh Npmber(Forkxal...nW Pennt Appmved(FoncmalueaoW PonnN Expuatlon Dale(Farkra/ass omlyJ CUPAFORM(4/99) Fofrnedy SWRCB Form B