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UNIFIED PROGRAM CONSOLIDATED FORM TANKS UNDERGROUND STORAGE TANKS - TANK PAGE 2 Paae VI.PIPING CONSTRUCTION(Check as that apply) UNDERGROUND PIPING ABOVEGROUND PIPING SYSTEM TYPE 1 PRESSURE ❑ 2. SUCTION ❑ 3. GRAVITY ❑ 1. PRESSURE ❑ 2. SUCTION 3. GRAVITY CONSTRUCTION/ 1. SINGLE WALL ❑ 3. LINEO TRENCH ❑99 OTHER 1. SINGLE WALL ❑95. UNKNOWN MANUFACTURER ❑ 2 DOUBLE WALL -/ ❑95. UNKNOWN ❑ 2. DOUBLE WALL 1-199. OTHER MANUFACTURER L/Yl`/I`e W/( / MANUFACTURER ❑ 1 BARE STEEL ❑ 6. FRP COMPATIBLE W/100%METHANOL ❑ 1. BARE STEEL ❑ 8. 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(HOPE) ❑99. OTHER ❑ 4. FIBERGLASS ❑ 8. FLEXIBLE(HOPE) ❑99 OTHER. ❑ 4 FIBERGLASS ❑ B. CATHODIC PROTECTION 5 STEEL WI COATING ❑ 9. CATHODIC PROTECTION 5. STEEL W/COATING 1:195. UNKNOWN VII.PIPING LEAK DETECTION(Check all that apply) UNDERGROUND PIPING ABOVEGROUND PIPING SINGLE WALL PIPING SINGLE WALL PIPING - PRESSURIZED PIPING(Check all that apply): PRESSURIZED PIPING(Check all that apply). ❑ 1. ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP SHUT OFF FOR ❑ 1. ELECTRONIC LINE LEAK DETECTOR 3.0 GPH 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 GPH TEST ❑ 2. MONTHLY 0 2 GPM TEST ❑ 3. ANNUAL INTEGRITY TEST(0.1 GRH) ❑ 3. ANNUAL INTEGRITY TEST(0.1 GPM) 4, DAILY VISUAL CHECK CONVENTIONAL SUCTION SYSTEMS. CONVENTIONAL SUCTION SYSTEMS(Check all that apply): ❑ 5. DAILY VISUAL MONITORING OF PUMPING SYSTEM+TRIENNIAL PIPING INTEGRITY ❑ 5. DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM TEST(0 1 GPH) ❑ 8. TRIENNIAL INTEGRITY TEST(0.1 GPM) �S.,A(FE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPINGy SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING)' IJU 7. SELF MONITORING ❑ 7. SELF MONITORING GRAVITY FLOW. G VITY FLOW(Check all that apply)' ❑ 9. BIENNIAL INTEGRITY TEST(0 1 GPH) 8. DAILY VISUAL MONITORING ❑ 9 BIENNIAL INTEGRITY TEST(0.1 GPH) 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 ❑ D AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM ❑ b. AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM DISCONNECTION DISCONNECTION ❑ C. NO AUTO PUMP SHUT OFF ❑ C. NO AUTO PUMP SHUT OFF ❑ 11 AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)WITH FLOW SHUT OFF OR ❑ RESTRICTION 11. AUTOMATIC LEAK DETECTOR ❑ 12. ANNUAL INTEGRITY TEST(0.1 GPM) ❑ 12. ANNUAL INTEGRITY TEST(0.1 GPH) SUCTION/GRAVITY 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 WITHOUT AUTO PUMP SHUT OFF AUDIBLE AND ❑ 14. CONTINUOUS SUMP CENSOR 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 GPH TEST) RESTRICTION ❑ 18. ANNUAL INTEGRITY TEST(0,1 GPH) ❑ 16. ANNUAL INTEGRITY TEST(0.1 GPH) ❑ 17. DAILY VISUAL CHECK ❑ IT DAILY VISUAL CHECK VIIL 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 ❑ 6. NONE IX.OWNERIOPERATOR SIGNATURE I certify that the information provided herein is We and 9#urate to the best of my knowledge. SIGNATURE OF OWNE PAT DATE NAM F WNER/q P T print TITLE OF OWNER/OPERATOR dr �rw3 - , 67y Permit Number(For local use only) Permit Approved(For local use only) Permit Expiration Date(For local use only) CUPAFORM(4199) Formerly SWRCB Form B