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UNIFIED PROGRAM CONSOLIDATED FORM TANKS UNDERGROUND STORAGE TANKS -TANK PAGE 2 assess Vi.PIPING CONSTRUCTION(chect.n ma I) P.ge_or_ UNDERGROUND PIPING ABOVEGROUND PIPING SYSTEM TYPE 0 L PRESSURE 0 2.SUCTION C 3.GRAVITY 458 0 1.PRESSURE 0 2. SUCTION 0 3.GRAVITY 459 CONSTRUCTION OI.SINGLE WALL 03.LINED TRENCH 099.OTHER 460 01.SINGLE WALL 095.UNKNOWN 462 MANUFACTURER 02.DOUBLE WALL 095.UNKNOWN 02.DOUBLE WALL 099.OTHER - MANUFACTURER 461 MANUFACTURER 463 0 1.BARE STEEL 0 6.FRP COMPATIBLE w/10W. METHANOL 0 1.BARE STEEL 0 6.FRP COMPATIBLE W11WAMETHANOL 0 2.STAINLESS STEEL 0 7.GALVANIZED STEEL 0 Unknown 0 2. STAINLESS STEEL 0 7.GALVANIZED STEEL 0 3.PLASTIC COMPATIBLE W/CONTENTS 0 99. Other 0 3. PLASTIC COMPATIBLE W/CONTENTS [--IS.FLEXIBLE(HDPE) 099. OTHER 04.FIBERGLASS O 9.FLEXIBLE(HOPE) 04. FIBERGLASS 09.CATHODIC PROTECTION 0 5.STEEL W/COATING 0 9.CATHODIC PROTECTION 464 0 5. STEEL W/COATING 0 95.UNKNOWN 465 VII.PIPING LEAK DETECT'IONaeck all that apply)AMcritarldthe mmiiwrin stall he submincd mus lost UNDERGROUND PIPING - ABOVEGROUND PIPING SINGLE WALL PIPING - 466 SINGLE WALL PIPING 467 PRESSURIZED PIPING(Checkall thatapplyL PRESSURIZED PIPING(Cbmkall thatapply): 0 I.ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP SHUT 0 1. ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST W11H AUTO PUMP OFF FOR LEAK,SYSTEM FAILURE,AND SYSTEM DISCONNECTION+ SHUT OFF FOR LEAK,SYSTEM FAILURE,AND SYSTEM DISCONNECTION+ AUDIBLE AND VISUAL ALARMS. AUDIBLE AND VISUAL ALARMS. 0 2.MONTHLY 01 GPH TEST 02. MONTHLY 0.2 GPH TEST 0 3.ANNUAL INTEGRITY TEST(0.1 GPH) 0 3.ANNUAL INTEGRITY TEST(O.IGPH) 0 4. DAILY VISUAL CHECK CONVENTIONAL SUCTION SYSTEMS CONVENTIONAL SUCTION SYSTEMS(Chmksll thetapply) 0 S.DAILY VISUAL MONITORING OF PUMPING SYSTEM+TRIENNIAL PIPING INTEGRITY TEST(0.1 GPH) ❑S. DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM SAFE SUCTION SYSTEMS(NO VALUES IN BELOW GROUNDPIPING): 0 6.TRIENNIAL INTEGRITY TEST(0.1 GPH) 0 7.SELF MONITORING SAFE SUCTION SYSTEMS(NO VALVES 1N BELOW GROUND PIPING): GRAVITY FLOW 07. SELF MONITORING 0 9.BIENNIAL INTEGRITY TEST(0.1 GPH) GRAVITY FLOW(Check all that apply): 0 8. DAILY VISUAL MONITORING 0 9. BIENNIAL INTEGRITY TEST(0.1 GPH) SECONDARILY CONTAINED PIPING SECONDARILY CONTAINED PIPING PRESSURIZED PIPING(Check all that apply): PRESSURIZED PIPING(Clack all that apply): 10. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL 10. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL ALARMS AND(Oheok one) ALARMS AND(Clack one) 0 a. AUTO PUMP SHUT OFF WHEN A LEAK OCCURS 0 a AUTO PUMP SHUT OFF WHEN A LEAK OCCURS 0 b. AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM 0 b AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM DISCONNECTION DISCONNECTION Cc. NO AUTO PUMP SHUT OFF Cc NO AUTO PUMP SHUT OFF 0 11. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)WITH FLOW SHUT 0 11 AUTOMATIC LEAK DETECTOR OFF OR RESTRICTION 0 12.-ANNUAL INTEGRITY TEST(0.1 GPH) 0 12. ANNUAL INTEGRITY TEST(0.1 GPH) SUCTION/GRAVITY SYSTEM SUCTION/GRAVITY SYSTEM 013. CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS 013.CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS EMERGENCY GENERATORS ONLY(Checkall that apply) EMERGENCY GENERATORS ONLY(CTeckall tlatapply) 0 14. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUTOFF• 0 14. CONTINUOUS SUMP SENSOR WrrHOUT AUTO PUMP SHUT OFF AUDIBLE AND VISUAL ALARMS AUDIBLE AND VISUAL ALARMS C 15. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)WITHOUT FLOW 015. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST) SHUT OFF OR RESTRICTION [116.ANNUAL INTEGRITY TEST(0.1 GPH) [116.ANNUAL INTEGRITY TEST(0.1 GPH) 0 17. DAILY VISUAL CHECK 0 17. DAILY VISUAL CHECK VIM.DISPENSER CONTAINMENT DISPENSER CONTAINMENT 0 1.FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE [14.DAILY VISUAL CHECK DATE INSTALLED 468 02.CONTINUOUS DISPENSER PAN SENSOR+AUDIBLE AND VISUAL ALARMS 05.TRENCH LINER/MONITORING 0 3.CONTINUOUS DISPENSER PAN SENSOR FM AUTO SHUT OFF FOR 0 6.NONE 469 DISPENSER+AUDIBLE AND VISUAL ALARMS IX.OWNER/OPERATOR SIGNATURE I cenifythen the iNumalion provided herein is true and accuras no the bestofmy kn4wkdge. SIGNATURE OF OWNERIOPERATOR DATE 470 NAME OF OWNER/OPRATOR(print) 471 1 TITLE OF OWNER/OPERATOR an Pesmit Harbor(For lend use only) 473 Permit Appoved(Far local use only) 474 Permit Fxpuaion Daa(For local use only) 475 UPCF(12/99 revised) 12 Formerly SV,RCB Form B