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UNIFIED PROGRAM CONSOLIDATED FORM TANKS UNDERGROUND STORAGE TANKS - TANK PAGE 2 Pape d VI.PIPING CONSTRUCTION(Check Y MdapgS - - LIDERGRDMND PIPING ABOVEGROUND PIPING SYSTEM TYPE I, PRESSURE ❑2 SUCTION ❑ ] GRAVITY 458 ❑ 1. PRESSURE ❑ 2. SUCTION ❑ 3. GRAVITY 459 CONSTRUCTION/❑ 1. SINGLE WALL ❑ 3 LINED TRENCH ❑99. OTHER 160 ❑ I. SINGLE WALL ❑95. UNKNOWN 462 MANUFACTURER&2. DOUBLE WALL ❑95 UNKNOWN ❑ 2. DOUBLE WALL ❑99. OTHER MANUFACTURER 481 MANUFACTURER 483 ❑ I.BARE STEEL ❑S FRP COMPATIBLE W/100%METHANOL ❑ 1. BARE STEEL ❑ B. FRP COMPATIBLE W/100%METHANOL MATERIALS AND ❑ 2. STAINLESS STEEL ❑ 7.GALVANIZED STEEL ❑ 2. STAINLESS STEEL ❑ 7. GALVANIZEDSTEEL CORROSK)N ❑ 3. PLASM COMPATIBLE%ATH CONTENTS ❑95. UNKNOWN ❑ 3. PLASTIC COMPATIBLE WITH CONTENTS ❑ 6. FLEXIBLE(HDPE) ❑W. OTHER PROTECTION $t4. FIBERGLASS ❑ 8. FLEXIBLE IHDPE) ❑89. OTHER ❑ 4. FIBERGLASS ❑ 9. GTNIOOIC PROTECTION ❑ 5. STEELW/COATING ❑ 9 CATHODICPROTECTION aW ❑ 5. STEELW/COATOG 09- UNKNOWN 465 VII.PIPING LEAK DETECTION(Chest M Mal eov" UNDERGROUND PIPING ABOVEGROUND PIPING SOSGLE WALL PIPING 468 SINGLE WALL PIPING 487 PRESSURIZED PIPING(Chackap that appy): PRESSURIZED APING(C alf Mat apply): ❑ 1. ELECTRONIC UNE LEAK DETECTOR 3 0 GPH TEST WITH AUTO PUMP SHUT OFF FOR ❑ 1. ELECTRONIC UNE LAK 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 GAN TEST ❑ 2. MONTHLY 02 GPH TEST ❑ 3. ANNUALINTEGRTTYTEST(0.1GPH) ❑ 3 ANNWILINTEGRITYTESTRIGIPH) ❑ 4. DAILYVISUALCHECK CONVENTIONAL SUCTION SYSTEMS(Check all that appy): CONVENTIONAL SUCTION SYSTEMS. ❑ 5. DAILY VISUAL MONITORING OF PUMPING SYSTEM.TRIENNIAL PIPING INTEGRITY ❑ S. DAILY VISUAL MONITORINGOF PIPING AND PUMPING SYSTEM TEST IDA GPH) ❑ S. TRIENNIAL INTEG2 TEST(0.1 GPH) SAFE SUCTION SYSTEMS(NOVALVES IN BELOWGROUND PIPING): SAFE SUCTION SYSTEMS NO VALVES IN BELOW GROUND PIPING): ❑ 7. SELF MONITORING ❑ 7. SELFMONITORING GRAVITY FLOW GRAVITY FLOW(Check IN Tat appy): ❑ 9 MENNIALINTEGRitt TEST(O.1GPH) ❑ B. GAILYVISUALMCATORING ❑ 9. BIENNIAL INTEGRITY TEST(0.1 GPH) SECONDARILY CONTAINED PIPO10 SECONDARILY CONTAINED PIPING PRESSURIZED PIPING(ChacYAp Maf appy)' PRESSURIZED PIPING(C.4d aN Mat appy): 10. CONTINUOUS TURBINE SUMP SENSOR`WMT AUDIBLE AND VISUAL ALARMS AND 10. CONTINUOUS TURSNE SUMP SENSOR WTH AUDIBLE AND VISUAL ALARMS AND(ch. (CNack one) ono) ❑ a. AUTO PUMP SHUT OFF MEN A LEAK OCCURS ❑ y AUTO PUMP SHUT OFF MEN A LEAK OCCURS 9LE. AUTO PUMP SHUT OFF FOR LEAKS SYSTEM FAILURE AND SYSTEM DISCONNECTION ❑ b. AUTO PUMP SHUT OFF FOR LEAKS.SYSTEM FAILURE AND SYSTEM DISCONNECTGN ❑ c. NO AUTO PUMPSHUT OFF ❑ C. NOAUTOA.VPSHUTOFF ❑ 11 OTR CTgN NE LEAK DETECTOR(30 GP`-EST)`ATH FLOW SHUT OFF OR RES ❑ 1 AUTOMATIC LE!✓-ETECTOR ❑ 12. ANNUAL INTEGRITY TEST(0.1 GPH) ❑ 12. ANNUAL INTEGRE"TEST(0.1 GPH) SUCTIONIGRAVITY SYSTEM: ❑ SUCTION/GRAVIttSYSTEV 13 CONTINUOUS SUMP SENSOR.AUDIBLE ANO VISUAL ALARMS ❑ 13. CONTINUOUS SUMP SENSOR.AUDIBLE AND VISUAL ALARMS EMERGENCY GENERATORS ONLY(ChdCk all that appy) EMERGENCY GENERATORS ONLY(Check all that appy) ❑ 14. CONTINUOUS SUMP SENSOR WTHOUT AL:^O PUMP SHUT OFF.AUDIBLE AND ❑ 14. CONTINUOUS SIN?SENSOR WITHOUT AUTO PUMP SHUT OFF.AUDIBLE AND VISUAL VISUALALARMS ALARMS ❑ 15. AUTOMATIC LINE LEDETECTOR LS.O GW'EST)WITHOUT FLOW SHUT OFF OR N( RESTRICTION ❑ 15. AUTOMATIC UNE_EAK DETECTOR(3.0 GPM TEST) ❑ 16. ANNUAL INTEGRITY TEST(0.1 GPH) ❑ 18. ANNUAL INTEGR-'TEST(0.1 GAN) ❑ 17 ONLY VISUAL CHECK ❑ 17. DAILY VISUAL __K VIII.DISPENSER CONTAINMENT DISPENSER CONTAINMENT ❑ 1. FLOAT MEOHAY M THAT SHUTS OFF SHEAR VALVE ❑ 4. ONLY VISUAL CHECK DATE INSTALLED 468 ❑ 2. CONTINUOUS-.SPENSER PAN SENSOR.AUDIBLE AND VISUAL ALARMS ❑ 5. TRENCH LINER: MONITORING 9 Lmb ❑ 3. CONTINUOUS='SPENSER PAN SENSOR WTH AUTO SHUT OFF FOR DISPENSER•+-.ISLE AND VISUAL ALARMS ❑ 6 NONE .63 IX OWNERIOPERATOR SIGNATURE 1 U t e 1 soon pmwo in is bus arc•-• rely to Ne East of my knowledge. ^ SIG U P T DATE N 4T0 071 TITLE 0 OWNERIOF'_-/ATIyO/IR +2 NAME O E TOR IM N) Perms NumEar(For local use mry) 473 Fe^M1 Pppmved)For)Oral use only) 474 1 Psrmit Ezpcallon Dala(ForlA;aluseonly! 5 I UPCF(1199) • • Forrnerly SWRCB Fc-8