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UNIFIED PROGRAM CONSOLIDATED FORM TANKS UNDERGROUND STORAGE TANKS - TANK PAGE 2 7 7 VI,PIPING CONSTRUCTION(CheckaifthatappW Pao of -� UNDERGROUND PIPING ABOVEGROUND PIPING SYSTEM TYPE ❑ 1 PRESSURE ❑ 2. SUCTION 03. GRAVITY 01. PRESSURE ❑ 2. SUCTION ❑ 3. GRAVITY CONSTRUCTION/ A 1. SINGLE WALL ❑ 3. LINED TRENCH ❑99. OTHER 1. SINGLE WALL ❑95. UNKNOWN MANUFACTURER ❑ 2, DOUBLE WALL ❑95. UNKNOWN 2. DOUBLE WALL 1199. OTHER MANUFACTURER MANUFACTURER ❑ 1.BARE STEEL ❑ 8. FRP COMPATIBLE W/100%METHANOL ❑ 1. BARE STEEL ❑ 6. FRP COMPATIBLE W/100%METHANOL MATERIALS AND ❑ 2, STAINLESS STEEL ❑ 7. GALVANIZED STEEL ❑ 2. STAINLESS STEEL ❑ 7. GALVANIZED STEEL CORROSION PROTECTION ❑ 3. PLASTIC COMPATIBLE WITH CONTENTS ❑95. UNKNOWN ❑ 3. PLASTIC COMPATIBLE WITH CONTENTS ❑ 8. FLEXIBLE(HDPE) ❑99. OTHER ❑ 4. FIBERGLASS ❑ 8. FLEXIBLE(HDPE) ❑99. OTHER ❑ 4. FIBERGLASS ❑ 9. CATHODIC PROTECTION 5. STEEL W/COATING ❑ 9.CATHODIC PROTECTION 5. STEEL Al COATING 1195. UNKNOWN VII.PIPING LEAK DETECTION(Check alt that apply) UNDERGROUND PIPING ABOVEGROUND PIPING SINGLE WALL PIPING SINGLE WALL PIPING PRESSURIZED PIPING(Check all that apply): PRESSURIZED PIPING(Check all Vial apply): ❑ 1. ELECTRONIC LINE LEAK DETECTOR 3.0 GPM TEST WITH 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 DISCONNECTION+AUDIBLE AND VISUAL SYSTEM FAILURE,AND SYSTEM DISCONNECTION+AUDIBLE AND VISUAL ALARMS ALARMS ❑ 2. MONTHLY 0.2 GPM TEST ❑ 2. MONTHLY 0.2 GPM TEST ❑ 3. ANNUAL INTEGRITY TEST(0.1 GPM) ❑ 3.ANNUAL INTEGRITY TEST(0.1 GPM) 4. DAILY VISUAL CHECK CONVENTIONAL SUCTION SYSTEMS: CONVENTIONAL SUCTION SYSTEMS(Check all that apply). 11 5. 5. DAILY VISUAL MONITORING OF PUMPING SYSTEM*TRIENNIAL PIPING INTEGRITY WL 5. 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): Of 7. SELF MONITORING ❑ 7. SELF MONITORING GRAVITY FLOW: GRAVITY FLOW(Check all that apply): 11W 9. BIENNIAL INTEGRITY TEST(0.1 GPM) B. DAILY VISUAL MONITORING ❑ 9. BIENNIAL INTEGRITY TEST(0.1 GPM) 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 ALARMS AND (Check one) 10.CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL 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 SYSTEM DISCONNECTION 11b.AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM DISCONNECTION ❑ c. NO AUTO PUMP SHUT OFF ❑ C. NO AUTO PUMP SHUT OFF ❑ 11. AUTOMATIC LINE LEAK DETECTOR(3.0 GPM TEST)WITH FLOW SHUT OFF OR ❑ 11.AUTOMATIC LEAK DETECTOR RESTRICTION ❑ 12. ANNUAL INTEGRITY TEST(0.1 GPM) ❑ 12. ANNUAL INTEGRITY TEST(0.1 GPM) SUCTIONIGRAVITY SYSTEM: SUCTION/GRAVITY 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 NATHOUT AUTO PUMP SHUT OFF+AUDIBLE AND ❑ 14. CONTINUOUS St IMP SENSOR WITHOUT AUTO PUMP SHUT OFF+AUDIBLE AND VISUAL VISUAL ALARMS ALARMS ❑ 15.AUTOMATIC LINE LEAK DETECTOR(3.0 GPM TEST)WITHOUT FLOW SHUT OFF OR ❑ 15. AUTOMATIC LINE LEAK DETECTOR(3.0 GPM TEST) RESTRICTION ❑ 16.ANNUAL INTEGRITY TEST(0.1 GPM) ❑ 18.ANNUAL INTEGRITY TEST(0.1 GPM) ❑ 17. DAILY VISUAL CHECK ❑ 17. DAILY VISUAL CHECK VRL DISPENSER CONTAINMENT DISPENSER CONTAINMENT ❑ 1. FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE 4. DAILY VISUAL CHECK DATE INSTALLED ❑ 2. CONTINUOUS DISPENSER PAN SENSOR+AUDIBLE AND VISUAL ALARMS ❑ 5. TRENCH LINER/MONITORING ❑ 3. CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR DISPENSER+AUDIBLE AND VISUAL ALARMS ❑B. NONE IX OWNER/OPERATOR SIGNATURE I cartity that the information vi5qd herein ispe and accurate to the best of my knowledge. SIGN T E TO DATE NA O R/ PERAT R dnt) TITLE OF OWNER/OPERATOR ,f uLL N 5 /n�2 - vi2• e/�ci Permit Number(For local use only) Permit Approved(For local use only) Permit Expiration Date(For local use only) CUPAFORM(4/99) Formerly SWRCB Form B