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[ UNDERGROUND UNIFIED PROGRAM CONSOLIDATED FORM 1 TANKS STORAGE TANKS - TANK PAGE 2 UNDERGROUND PIPING PIPING CONSTRUCTION(Checka rthetappy) SYSTEM TYPE ABOVEGROUND PIPING I. PRESSURE ❑ Z. SUCTION ❑ 3. GRAVITY ❑ 1. PRESSURE ❑ 1. SINGLEWALL ❑ 3. LINEDTRENCH ❑ 2. SUCTION ❑ 3. GRAVITY MANUFACTURER OW ❑99. OTHER ❑ 1. SINGLE WALL MANUFACTURER 2. DOUBLE WALL 1195. UNKNOWM1195. UNKNOWN MANUFACTURER ❑ 2. OOVBLE WALL ❑99. OTHER MANUFACTURER 111.BARE STEEL ❑ B. FRP COMPATIBLE W/100%METHANOL ❑ 1. BARE STEEL MATERIALS AND ❑ Z. STAINLESS STEEL ❑ T. GALVANIZED STEEL ❑ 8. FRP COMPATIBLE W/100%METHANOL CORROSION ❑ 2. STAINLESS STEEL ❑ T.GALVANIZED STEEL PROTECTION ❑ 3. PLASTICCOMPATBLEWTH CONTENTS 09. UNKNOWN ❑ 3. PLASTIC COMPATIBLE WITH CONTENTS ❑ 8. FLEXIBLE(HOPE) 13 99 OTHER ❑ 4. FIBERGLASS ❑ 8. FLEXIBLE(HDPE) ❑99. OTHER ❑ L FIBERGLASS Cl S.STEEL WIC DATING ❑ 9, CATHODIC PROTECTION139. CATHODIC PROTECTION ❑ 5. STEEL WICOATING 1195, UNKNOWM VII.PIPING LEAK DETECMON(Check a8thaf apply) UNDERGROUND PIPING SINGLE WALL PIPING ABOVEGROUND PIPING PRESSURIZED PIPING(Check Bethel apply): SINGLE WgLL PIPING ❑ 1. ELECTRONIC LINE LEAK DETECTOR 3.0 GPM TEST WITH AUTO PUMP SHUT OFF FOR PREBSULECTR NIC (OE LEAK DETECTOR LEAK,SYSTEM FAILURE,AND SYSTEM DISCONNECTION+AUDIBLE AND VISUAL ❑ 1. ELECTRONIC UNE LEAK DETECTOR 3.0 GPM TEST WITH AUTO PUMP SHUT OFF FOR LEAK, ALARMS SYSTEM FAILURE.AND SYSTEM DISCONNECTION+AUDIBLE AND VISUAL 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): ❑ 5. DAILY VISUAL MONITORING OF PUMPING SYSTEM+TRIENNIAL PIPING INTEGRITY t ❑ S. DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM TEST(0.1 GPM) '^ ❑ . SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): 8, TRIENNIAL INTEGRITY TEST(0 1 GPM) ❑ T. SELF MONITORING SAFE SUCTION SYSTEMS(NO VALVES IN SELOWGROUND PIPING): GRAVITY FLOW 11T. SELF MONITORING ❑ 9. BIENNIAL INTEGRITY TEST(0 1 GPM) a GRAVITY FLOW(Check an that apply)) ❑ 8. DAILY VISUAL MONITORING ❑ SECONDARILY CONTAINED PIPING S. BIENNIAL INTEGRITY TEST(0.1 GPM) PRESSURIZED PIPING(Chock a8 Mat apply); SECONDARILY CONTAINED PIPING 10, CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL PRESSURIZED PIPING(Checkall that apply); (Check one) 10.CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL ALARMS AND(check ane) a.AUTO PUMP SHUT OFF FOR L A KS,S OCCURS ❑ x. AUTO PUMP SHUT OFF WHEN A LEAK OCCURS gAUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM DISCONNECTION ❑ b. 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 IS0 GPM TEST)WITH FLOW SHUT OFF OR RESTRICTION ❑ 11. AUTOMATIC LEAK DETECTOR ❑ 12, ANNUAL INTEGRITY TEST 10.1 GPH) ❑ 12. ANNUAL INTEGRITY TEST(0.1 GPM) SOCTIONMaRAVITY SYSTEM: SUCTION/GRAVITY SYSTEM: ❑ 13. CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS ❑ 13. CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS EMERGENCY GENERATORS ONLY(Check a8 OeNpFy) ❑ 14. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SMUT OFF+AUDIBLE AND EMERGENCY GENERATORS ONLY(Cock aB Met appryq VISUAL ALARMS ❑ 14.CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SMUT OFF+AUDIBLE AND VISUAL ❑ 15. AUTOMATIC LINE LEAK DETECTOR(3.0 GIOH TEST)WITHOUT FL0W SHUT OFF ALARMS RESTRICTION 0R ❑ 15. AUTOMATIC LINE LEAK DETECTOR(10 GPM TEST) ❑ 18. ANNUAL INTEGRITY TEST IDA GPM) ❑ 1TDAILY VISUAL CHECK 18. ANNUAL INTEGRITY TEST(0.1 GPM) ❑ . ❑ 1l. DAILY VISUAL CHECK VIIL DISPENSER CONTAINMENT DISPENSER CONTAINMENT ❑ 1. FLOATMECHANISMTHAT SHUTS OFF SHEAR VALVE DATE INSTALLED ❑ 2. CONTINUOUS DISPENSER PAN SENSOR+AUDIBLE AND VISUAL ALARMS ❑ a, DRENCH LINER IMCK ❑ 3.CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR DISPENSER+AUDIBLE AND VISUAL ALARMS ❑ B. NONE HDNERONRORING I comf,Nal Na InlormaUon pmvide Mrein u bye ane eavnta to Me bail of my knovAeU9aX OWNER/OPERATOR SIGNATURE SIGNATURE OF OWNERIOPERATOR DATE NAME OF OWNERIOPERATOR tph Q TITLE OF OVMERIOPERATDR I Pamril Number(Fbrbcal uxe w NI Permit Apprevap(Forbcal uea ohW Parma EzpireUon Data(Fartpal vxa omy) CUPAFORM(4/99) Fo nerly SWRCB Farm 8