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Ask UNIFIED PROGRAM CONSOLIDATED Fon TANKS UNDERGROUND STORAGE TANKS - TANK PAGE 2 VI.PIPING CONSTRUCTION(Chock aplhatappW UNDERGROUND PIPING ABOVEGROUND PIPING SYSTEM TYPE 1 PRESSURE El 2. SUCTION ❑ ]. GRAVITY ❑ 1. PRESSURE ❑ 2. SUCTION ❑ ]. GRAVITY CONSTRUCTION/ T SINGLE WALL ❑ ]. LINED TRENCH 1199 OTHER ❑ 1. SINGLE WALL 1195 UNKNOWN MANUFACTURER 2. DOUBLE WALL ❑95. UNKNOWN e El 2. DOUBLE WALL 1199. OTHER MANUFACTURER PauU1rOF MANUFACTURER ❑ 1 BARE STEEL ❑ B. FRE COMPATIBLE W/10094 METHANOL ❑ L BARE STEEL ❑ e. FRP COMPATIBLE WI 100%METHANOL MATERIALS AND ❑ 2. STAINLESS STEEL ❑ T. GALVANIZED STEEL ❑ 2. STAINLESS STEEL ❑ T. GALVANIZED STEEL CORROSION PROTECTION ❑ ]. PLASTIC COMPATIBLE WITH ONTENTS 1195 UNKNOWN ❑ ]. PLASTIC COMPATIBLE WITH CONTENTS ❑ 9. FLE)(IBLE(HDPE) 1199 OTHER d 4 FIBERGLASSEra. FLEXIBLE(HDPE) 1199 OTHER. ❑ 4. FIBERGLASS ❑ e. CATHODIC PROTECTION 5 STEEL W/COATING ❑ 9. CATHODIC PROTECTION ❑ 5. STEELWICOATING 1195. UNKNOWN VII.PIPING LEAK DETECTION(Check aOlhefeppy) UNDERGROUND PIPING AEOVEGROUND PIPING SINGLE WALL PIPING SINGLE WALL PIPING PRESSURIZED PIPING(Check all that apply): PRESSURIZED PIPING(Ch Kk eft Met appy): ❑ 1. ELECTRONIC UNE LEAK DETECTOR 3.0 GPM TEST WITH AUTO PUMP SHUT OFF FOR ❑ 1. ELECTRONIC LINE LEAK DETECTOR 0.0 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 EST ❑ 2. MONTHLY 02 GPn TEST ❑ 2. ANNALINTY 0 EGITYPM TES ❑ ]. ANNUAL INTEGRITY TEST(0.1 GPM) ❑ ]. ANNUAL INTEGRITY TEST(0 1 GPM) ❑ 4. DAILY VISUAL CHECK CONVENTIONAL SUQTION SYSTEMS: CONVENTIONAL SUCTION SYSTEMS(Check all that appy): ❑ 5. DALLY VISUAL MDNITORINC OF PUMPING SYSTEM-TRIENNIAL PIPING INTEGRITY ❑ 5. DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM TEST(01 OF ❑ 9. TRIENNIAL INTEGRITY TEST(DI GPM) SAFE SUCTION SYSI EMS(NO VALVES IN BELOW GROUND PIPING)r SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPINGI' ❑ T. SELF MONITC RING ❑ T. SELF MONITORING GRAVITY FLOW. GRAVITY FLOW(Check all that apply): ❑ 9. BIENNIAL Iry GRITY TEST(0.1 GPH1 ❑ 8. DAILY VISUAL MONITORING ❑ 9 BIENNIAL INTEGRITY TEST CA GPM) SECONDARILY CONTAINED PIPING SECONDARILY CONTAINED PIPING PRESSURIZED PIPING(Check all that apply) PRESSURIZED PIPING(Check aft Mat vppy): 10. CONTINUOUS TURBINE SUMP SENSOR WTH AUDIBLE AND VISUAL ALARMS AND 10.CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL ALARMS AND Nck one) (DnNTI one) Ic e ❑yAUTUTO PUMP SHUT OFFWHEN A LEAK OCCURS ❑ a. AUTO PUMPSHUTOFFWMENA LEAKOCCURS 'rAUTO O PUMP SHUT OFF FOR LEAKS.SYSTEM FAILURE AND SYSTEM DISCONNECTION ❑ 0, AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM DISCONNECTION �/❑ c. NOAUTO PUMP SHUT OFF ❑ c. NOAUTOPUMPSHUTOFF 0 11. AUTOMATIC LINE LEAK DETECTOR(30 GPM TEST)WITH FLOW SHUT OFF OR ❑ 11. AUTOMATIC LEAK DETECTOR RESTRICTION ❑ 12. ANNUAL INTEGRITY TEST to.t GPM) ❑ 12. ANNUAL INTEGRITY TEST IDA GPH) SUCTIONIGRAVITY SYSTEM SUCTION/GRAVITY SYSTEM: ❑ U. CONTINUOUS SUMP SENSOR♦AUDIBLE AND VISUAL ALARMS ❑ 13. CONTINUOUS SUMP SENSOR•AUDIBLE AND VISUAL ALARMS EMERGENCY GENERATORS ONLY(Chock aft that apply) EMERGENCY GENERATORS ONLY(Check a0 that apply) ❑ 14. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF•AUDIBLE AND ❑ u.CONTINUOUS SUMP SENSOR VATHOUT AUTO PUMP SHUT OFF a AUDIBLE AND VISUAL VISUALALARMS ALARMS ❑ 15. AUTOMATIC LINE LEAK DETECTOR(3.0 GPM TEST)WTHOUT FLOW SHUT OFF OR ❑ 15. AUTOMATIC LINE LEAK DETECTOR(3.0 GPM TEST) RESTRICTION ❑ 16. ANNUAL INTEGRITY TEST ID.I GPM) ❑ 19. ANNUAL INTEGRITY TEST(0 1 GPM) ❑ 17. DAILYVISUA CHECK ❑ 1T. DAILY VISUAL CHECK VIII.DISPENSER CONTAINMENT DISPENSER CONTAINMENT ❑ 1. FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE ❑ 4. DMLYVISUALCKECK DATE INSTALLED ,❑p�CONTIN000S DISPENSER PAN SENSOR•AUDIBLE AND VISUAL ALARMS ❑ S. TRENCH LINER I MONITORING 6]. CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR DISPENSER•AUDIBLE AND VISUAL ALARMS ❑ B, NONE IX OWNER/OPERATOR SIGNATURE I oerey Mat Ne info ahon provided herein is We arw&=rats W the Oast of my a0ovil"go. SIGNATURE OF ON ERAIP TOR ` DATE Q /! NAME OF !ER'OPERgTOG Open TITLE 0 $n4S1ER PER TOR Fermin Number(Forlocal eve orgy) Permit Approved(Forloul ms orgy) Pennd Eapira ton Date(Forbnl we only) CUPAFORM(4199) Formerly SWRCB Form B