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s UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANKS - TANK PAGE 2 TANKS Pe d _ VI.PIPING CONSTRUCTION(Check 0 mat IMW UUWERGRCUID PIPING ABOVEGROUND PIPING SYSTEM TYPE &1. PRESSURE ❑2 SUCTION ❑ 1 GRAVITY 458 ❑ 1. PRESSURE ❑ t. SUCTION ❑ 3. GRAVITY 459 MA NgW ❑ 1. SINGLE WALL ❑ 3 LINED TRENCH ❑99. OTHER 160 ❑ 1. SINGLE WALL 1195. UNKNOWN 462 MANUFACTURER fj�2. DOUBLE WALL ❑9S UNKNOWN ❑Z. DOUBLE WALL ❑99. OTHER MANUFACTURER 481 MANUFACTURER 463 ❑ 1.WE STEEL ❑6.FRP COMPATIBLE WI I(X%METHANOL ❑ 1. BARE STEEL ❑ 6. FRP COMPATIBLE WI 100%MU ANQ MATERIALS AND ❑2 STAINLESS STEEL ❑ 7. GALVANREDSTEEL ❑2. STAINLESS STEEL ❑ 7. GALVANIZED STEEL CORROSIOPROTECTION ❑0 3. PLASTIC COMPATIBLE WITH CONTENTS ❑95. UNKNOWN ❑ 3. PLASTIC COMPATIBLE WITH CONTENTS ❑ 8. FLEXIBLE(HOPE) ❑W. OTHER q 4. FIBERGLASS ❑3. FLEXIBLE(HOPE) ❑99. OTHER ❑ 4. FIBERGLASS ❑ 9. CATHODIC PROTECTION ❑ S. STEEL W]COATING ❑ 9 CATHODIC PROTECTION 164 105, STEEL W/COATIS ❑95. UNKNOWN M5 VII.PIPING LEAK DETECTION(Chant a"apply, UNDERGROUND PIPING ABOVEGROUND PIPING SINGLE WALL PIPING d6fi SINGLE WALL PIPING a67 PRESSURIZED PIPING(Chac*W&A appy). PRESSURIZED PIPING(04 all Nat appy): ❑ 1. ELECTRONIC UNE LEAK DETECTOR 30 GRH TEST WITH AUTO PUMP SHUT OFF FOR ❑ 1. ELECTRONIC LINE_EAK DETECTOR 3.0 GPH TEST PL AUTO PUMP SHUT OFF FOR LEAK LEAK SYSTEM FAILURE.AND SYSTEM DISCONNECTION•AUDIBLE AND VISUAL SYSTEM FAILURE AND SYSTEM DISCONNECTION s AUDIBLE AND VISUAL ALARMS ALARMS ❑ 2 MONTHLY 03 GRH TEST ❑ 2 MONTHLY 02 GPH TEST ❑ 3. ANNUAL INTEGRITY TEST(0.1 GPH) ❑ 1 ANNUAL INTEGRITY TEST(0.1GPL) ❑ 4. pAILYWSUAICIE:K CONVENTIONAL SUCTION SYSTEMS: CONVENTIONAL SUCTION SYSTEMS(Check all that apply): ❑ 5 DAILY VISUAL MONITORINGOF PUMPING SYSTEM•TRIENNIAL PIPING INTEGRITY ❑ 5. DAILY VISUAL MONTORING OF PIPING AND PUMPING SYSTEM TEST(0.1 GPH) ❑ 6. TRIENNIAL INTEGRTY TEST(0.1 GPH) SAFE STICTION SYSTEMS(NOVALVES IN BELOWGROUND PIPING): SAFE SUCTION SYSTEMS RIO VALVES IN BELOW GROUND PIPING): ❑ 7. SELF MONITORING ❑ 7. SELF MONITORING GRAVITY FLOW GRAVITY FLOW(Check a[Naf appy): ❑ 9. BIENNIALINTEGRITYTEST(Ol GPH) ❑ B. DAILYVISUALMONTORING ❑ 9. BIENNIAL INTEGRRY TEST(0.1 GPH) SECONDARILY CONTAINED PIPING SECONDARILY CONTAINED PIPING PRESSURIZED PIPING(Checkall Nat APpy1: PRESSURIZED PIPING(Crock all that appy): 10. CONTINUOUS TURBINE SUMP SENSOR W=AUOIBLE AND VISUAL ALARMS AND 10. CONTINUOUS TUF91NE SUMP SENSOR VATH AUDIBLE AND VISUAL ALARMS AND(cl,. xA ma (Ch ) Dost ❑ a. AUTO PUMP SHUT OFF WHEN A LEAK OCCURS �. ❑ a.AUTO PUMP SHUT OFF MEN ALEAK OCCURS b AUTO SHUT OFF FOR LEAKS SYSTEM FAILURE AND SYSTEM DISCONNECTION TION ❑ 0. AUTO PUMP SHUT OFF FOR LEAKS.SYSTEM FAILURE AND SYSTEM DISCONNECT'CN ❑ c. NO AUTO PUMPSHUr OFF ❑ C. NO AUTO P_MP SHUT OFF ❑ 11. AUTOMATIC LINE LEAK DETECTOR(30 GP--EST)WITH FLOW SHUT OFF OR RESTRICTION ❑ 11 AUTOMATIC LEAe:ETECTOR ❑ 12. ANNUAL INTEGRITY TEST(0.1 GPH) ❑ 12. ANNUAL INTEGR-TEST(0.1 GPH) SUCTIONIGRAVITY SYSTEM: ❑ 13 CONTINUOUS SUMP SENSOR-AUDIBLE AND VISUAL ALARMS SUCTIONGRAVITY SYSTEM ❑ 13. CONTINUOUS SUMP SENSOR-AUDIBLE AND VISUAL ALARMS EMERGENCY GENERATORS ONLY(Check all that appyl ❑ 14. CONTINUOUS SUMP SENSOR WITHOUT AU70 PUMP SHUT OFF a AUDIBLE AND EMERGENCY GENERATORS ONLY(CIIecot all that appy) VISUALALARMS ❑ 14. CONTINUOUS SITUP SENSOR WITHOUT AUTO PUMP SHUT OFF.AUDIBLE AND VISUAL ❑ 15. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH'EST)WITHOUT FLOW SHUT OFF OR ALARMS RESTRICTION ❑ 15. AUTOMATIC UNE FAX DETECTOR(3.0 GPH TEST) ❑ 16. ANNUAL INTEMITY TEST(0.1 GPHI ❑ 17 CmLYVISUALCHECK ❑ 18. ANNUAL VISUAL S TEST(0.1 GPM) C31]. DAILY VISUAL CF_CK VIII.DISPENSER CONTAINMENT DISPENSER CONTAINMENT ❑ 1. FLOAT MEONAYSM THAT SHUTS OFF SHFAR VALVE ❑ 4. DAILY VISUAL CHECK DATE INSTALLED a6S ❑ 2. CONTINUOUS-,SPENSER PAN SENSOR-AUDIBLE AND VISUAL ALARMS ❑ 5. TRENCH UNER: MONITORING ❑ 3. CONTINUOUS:-SPENSER PAN SENSOR WITH AUTO SHUT OFF FOR DISPENSER=_:IBLE AND VISUAL ALARMS ❑ 6. NONE 469 IX.OWNER/OPERATOR SIGNATURE I to op p I,Irain is hue arc an rots to Na beet of my kno .dge. NAT F E OR DATE S-- (4--of '70 k ME ET ( 1 W 471 TITLE OFOWNYERI/O`PP-_=ATOR 4'2 � ✓ uv PINllllt Numw(Forlocal Psemryl 473 1 Fs-a ApWovee(Fprlppal useohly) 47d Perm4E yintan Date(ForlOnal use poly -5 UPCF(1/99) Formerly SWRCB Fr-B