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U IED PROGRAM CONSOLIDATED FOR <br /> TANK <br /> UNDERGROUND STORAGE TANKS - TANK PAGE 2 <br /> Page_of <br /> VI.PIPING CONSTRUCTION(Check all that apply) <br /> UNDERGROUND PIPING ABOVEGROUND PIPING <br /> SYSTEM TYPE ®1.PRESSURE ❑2.SUCTION ❑3.GRAVITY 450 ❑1.PRESSURE ❑2. SUCTION [13.GRAVITY 466 <br /> CONSTRUCTION/ ❑1.SINGLE WALL ❑3.LINED TRENCH [199.OTHER 460 [11.SINGLE WALL ❑95.UNKNOWN 462 <br /> MANUFACTURER ®2.DOUBLE WALL [195,UNKNOWN ❑2.DOUBLE WALL ❑99.OTHER <br /> 463 <br /> MANUFACTURER Environ 461 MANUFACTURER <br /> ❑1.BARE STEEL ❑6.FRP COMPATIBLE WIIOD% METHANOL [11.BARE STEEL [16.FRP COMPATIBLE Wn00%MErHANOL <br /> ❑2.STAINLESS STEEL ❑7.GALVANIZED STEEL ❑UKNOWN ❑2. STAINLESS STEEL ❑7.GALVANIZED STEEL <br /> ❑3.PLASTIC COMPATIBLE W/CONTENTS [199. OTHER ❑3. PLASTIC COMPATIBLE WI CONTENTS ❑B.FLEXIBLE(HDPE) [199. OTHER <br /> ®4.FIBERGLASS ®B.FLEXIBLE(HDPE) ❑4. FIBERGLASS ❑9.CATHODIC PROTECTION <br /> ❑5.STEEL W/COATING ❑9.CATHODIC PROTECTION 464 ❑5. STEEL WICOATING [195.UNKNOWN 465 <br /> VII.PIPING LEAK DETECTION(Check all that apply)(A tlescriphon of the monitoring program shall be submitted to the local agency.) <br /> UNDERGROUND PIPING ABOVEGROUND PIPING <br /> SINGLE WALL PIPING 466 SINGLE WALL PIPING 467 <br /> PRESSURIZED PIPING(Check al mat apply): PRESSURIZED PIPING(Check all that apply): <br /> ❑1. ELECTRONIC UNE LEAK DETECTOR 3.0 GPH TEST NTH AUTO PUMP SHUT OFF FOR [11. ELECTRONIC UNE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP SHUT OFF FOR <br /> LEAK,SYSTEM FAILURE,AND SYSTEM DISCONNECTION+AUDIBLE AND VISUAL LEAK SYSTEM FAILURE,AND SYSTEM DISCONNECTION+AUDIBLE AND VISUAL <br /> ALARMS. <br /> [12. MONTHLY 0.2 GPH TEST ❑2. MONTHLY 0.2 GPH TEST <br /> ❑3. ANNUAL INTEGRITY TEST(0.1 GPI ❑3. ANNUAL INTEGRITY TEST(0.1GPH) <br /> ❑4. DAILY VISUAL CHECK <br /> CONVENTIONAL SUCTION SYSTEMS CONVENTIONAL SUCTION SYSTEMS(Check as that apply) <br /> ❑5. DAILY VISUAL MONITORING OF PUMPING SYSTEM+TRIENNIAL PIPING INTEGRITY 05. DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM <br /> TEST(0.1 GPH) <br /> SAFE SUCTION SYSTEMS(NO VALUES IN BELOW GROUNDPIPING): 06. TRIENNIAL INTEGRITY TEST(0.1 GPH) <br /> ❑7. SELFMONITORING SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): <br /> GRAVITY FLOW 07. SELF MONITORING <br /> 09. BIENNIAL INTEGRITY TEST(0.1 GPH) GRAVITY FLOW(Chea all that apply): <br /> [18. DAILY VISUAL MONITORING <br /> ❑9. BIENNIAL INTEGRITY TEST(0.1 GPH) <br /> SECONDARILY CONTAINED PIPING SECONDARILY CONTAINED PIPING <br /> PRESSURIZED PIPING(Check all that apply): PRESSURIZED PIPING(Check all that apply): <br /> 10. CONTINUOUS TURBINE SUMP SENSORWITH AUDIBLE AND VISUAL ALARMS AND 10. CCONNTTINNUhwk UOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL ALARMS AND <br /> (Checkers) <br /> ❑a. AUTO PUMP SHUT OFF WHEN A LEAK OCCURS ❑a AUTO PUMP SHUT OFF WHEN A LEAK OCCURS <br /> Ob. AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM Ob <br /> DISCONNECTION OPUMPSHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM <br /> DISCONNECTION <br /> Oc. NOAUTO PUMP SHUT OFF Oc NO AUTO PUMP SHUT OFF <br /> ®11. AUTOMATIC UNE LEAK DETECTOR(3.0 GPH TEST)WITH FLOW SHUTOFF OR [111. AUTOMATIC LEAK DETECTOR <br /> RESTRICTION <br /> ®12. ANNUAL INTEGRITY TEST(0.1 GPH) ❑12. ANNUAL INTEGRITY TEST(0.1 GPH) <br /> SUCTIONIGRAVITY SYSTEM SUCTION/GRAVITY SYSTEM <br /> ❑13. CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS 013. CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS <br /> EMERGENCY GENERATORS ONLY(Check all that apply) EMERGENCY GENERATORS ONLY(Check all that apply) <br /> ❑14. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF AUDIBLE AND ❑14. CONTAMUUOAUSSUMP SENSOR WITHOUT AUTO PUMP SHUT OFF+AUDIBLE AND <br /> VISUALALARMS <br /> RMS <br /> ❑15. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)WITHOUT FLOW SHUT OFF OR [3 15. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST) <br /> RESTRICTION <br /> 016. ANNUAL INTEGRITY TEST(0.1 GPH) ❑16. ANNUAL INTEGRITY TEST(0.1 GPH) <br /> ❑17. DAILY VISUAL CHECK ❑17. DAILY VISUAL CHECK <br /> VIII.DISPENSER CONTAINMENT <br /> DISPENSER ❑1. FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE =CKECK <br /> CONTAINMENT <br /> DATE INSTALLED 466 E3 2. CO NUOUS DISPENSER PAN SENSOR+AUDIBLE AND VISUAL ALARMS ZOOS ®3 AUD NTMUOUS DISPENSER PAN <br /> ANDVISUAL ALARMS SENSOR WITH AUTO SHUT OFF FOR DISPENSER+ sIX OWNERIOPERATOR SIGNATUREI certify that e i oonatio I - rue and accurate to the best of my knowledge. 470 <br /> SIGNA NER/OP TOR DATE / I <br /> NAME OWNER/OPRATOR(print) TITLE F OW ER/OPERATOR 472 <br /> Rand Martin Environmental Manaer <br /> Permit Number(Far local use only) 473 Pemrit Approved(For local use only) Permit Expiration Date(For local use only) <br /> 475 <br /> UPCF (1/99 revised) Formerly SWRCB Form B <br />