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Ion <br /> UNIFIED PROGRAM (UP) FORM Lc�/ y�o'j KQ <br /> UNDERGROUND STORAGE TANKS - TANK PAGE 2 <br /> VI. PIPING CONSTRUCTION(Check all that apply) Page of <br /> UNDERGROUND PIPING ABOVEGROUND PIPING <br /> SYSTEM TYPE ®1.PRESSURE 0 2.SUCTION 03.GRAVnV ase 0 1.PRESSURE 0 2. SUCTION 0 3.GRAVITY 459 <br /> CONSTRUCTION 0 1.SINGLE WALL 0 3.LINED TRENCH 099.OTHER 460 0 1.SINGLE WALL 0 95.UNKNOWN 462 <br /> MANUFACTURER 0 2.DOUBLE WALL [195.UNKNOWN 0 2.DOUBLE WALL 0 99.OTHER <br /> MANUFACTURER j r'Ti r-J ✓ 461 MANUFACTURER 463 <br /> MATERIALS AND 0 1 BARE STEEL 0 6.FRP COMPATIBLE w/100% 01.BARE STEEL 0 6.FRP COMPATIBLE W/700%METHANOL <br /> CORROSION METHANOL <br /> PROTECTION 0 2.STAINLESS STEEL 0 7.GALVANIZED STEEL 02.STAINLESS STEEL 0 7.GALVANIZED STEEL <br /> 0 95.UNKNOWN <br /> 0 3.PLASTIC COMPATIBLE W/CONTENTS 0 8.FLEXIBLE(HDPE) 03.PLASTIC COMPATIBLE ❑8.FLEXIBLE(HDPE)❑95.UNKNOWN <br /> W/CONTENTS <br /> 0 4.FIBERGLASS 0 9.CATHODIC PROTECTION 0 4. FIBERGLASS 0 9.CATHODIC PROTECTION <br /> 0 5.STEEL W/COATING 0 99.OTHER 464 1 0 5. STEEL W/COATING 0 99. OTHER 45 <br /> VII.PIPING LEAK DETECTION Check all Matapply)(A description of Me nionitorng program shall Ire suomittm M the local agency.) <br /> UNDERGROUND PIPING ABOVEGROUND PIPING <br /> SINGLE WALL PIPING 466 SINGLE WALL PIPING 467 <br /> PRESSURIZED PIPING(Check all Mat apply): PRESSURIZED PIPING(Check all Mat apply): <br /> 0 1.ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP 0 1. ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP <br /> SHUT OFF FOR LEAK,SYSTEM FAILURE,AND SYSTEM SHUT OFF FOR LEAK,SYSTEM FAILURE,AND SYSTEM <br /> DISCONNECTION+AUDIBLE AND VISUAL ALARMS. DISCONNECTION+AUDIBLE AND VISUAL ALARMS. <br /> 0 2.MONTHLY 0.2 GPH TEST 02. MONTHLY 0.2 GPH TEST <br /> 0 3.ANNUAL INTEGRITY TEST(0.1 GPH) [13.ANNUAL INTEGRITY TEST(0.1 GPH) 04. DAILY VISUAL CHECK <br /> CONVENTIONAL SUCTION SYSTEMS(Check all Mat apply) CONVENTIONAL SUCTION SYSTEMS(Check all Mat apply) <br /> [15.DAILY VISUAL MONITORING OF PUMPING SYSTEM+TRIENNIAL PIPING 0 5. DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM <br /> INTEGRITY TEST(0.1 GPH) <br /> O 6. TRIENNIAL INTEGRITY TEST(0.1 GPH) <br /> SAFE SUCTION SYSTEMS(NO VALUES IN BELOW GROUNDPIPING): SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): <br /> 0 7.SELF MONITORING 0 7. SELF MONITORING <br /> GRAVITY FLOW GRAVITY FLOW(Check all Mat apply): <br /> 0 9.BIENNIAL INTEGRITY TEST(0.1 GPH) 08.DAILY VISUAL MONITORING 09.BIENNIAL INTEGRITY TEST(0.1 GPH) <br /> SECONDARILY CONTAINED PIPING SECONDARILY CONTAINED PIPING <br /> PRESSURIZED PIPING(Check all that apply): PRESSURIZED PIPING(Check all that apply): <br /> 10. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL 10. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL <br /> ALARMS AND(Check one) ALARMS AND(Check one) <br /> 0 a. AUTO PUMP SHUT OFF WHEN A LEAK OCCURS 0 a AUTO PUMP SHUT OFF WHEN A LEAK OCCURS <br /> 0 It. AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND 0 to AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM <br /> SYSTEM DISCONNECTION DISCONNECTION <br /> Oc. NO AUTO PUMP SHUT OFF Oc NO AUTO PUMP SHUT OFF <br /> All 1. AUTOMATIC LEAK DETECTOR(3.0 GPH TEST) WITHFLOW SHUT OFF 0 11. AUTOMATIC LEAK DETECTOR <br /> 0 12. ANNUAL INTEGRITY TEST(0.1 GPH) O 12. ANNUAL INTEGRITY TEST(0.1 GPH) <br /> SUCTION/GRAVITY SYSTEM SUCTION/GRAVITY SYSTEM <br /> 013. CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS 013. CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS <br /> EMERGENCY GENERATORS ONLY(Check all Mat apply) EMERGENCY GENERATORS ONLY(Chock all that apply) <br /> 0 14. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF• 0 14. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF' <br /> AUDIBLE AND VISUAL ALARMS AUDIBLE AND VISUAL ALARMS <br /> Cl 15. AUTOMATIC LEAK DETECTOR(3.0 GPH)WITHOUT FLOW SHUT OFF 015. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST) <br /> 0 16.ANNUAL INTEGRITY TEST(0.1 GPH) 0 17. DAILY VISUAL CHECK 0 16.ANNUAL INTEGRITY TEST(0.1 GPH) 0 17. DAILY VISUAL CHECK <br /> VIII.DISPENSER CONTAINMENT <br /> DISPENSER CONTAINMENT 01..FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE 0 4.DAILY VISUAL CHECK <br /> DATE INSTALLED 468 0 2.CONTINUOUS DISPENSER PAN SENSOR-AUDIBLE AND VISUAL ALARMS ❑5.TRENCH LINER/MONITORING <br /> 0 3.CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR ❑6.NONE 469 <br /> DISPENSER+AUDIBLE AND VISUAL ALARMS <br /> IX.OWNERIOPERATOR SIGNATURE <br /> I certify Mat the informe8on provi is one and a=X!M the best of my knowledge. <br /> SIGNATURE OF OW R/ R I DATE 470 <br /> / _� <br /> NAME OF OWN (pnnQ TITLE OF OWNER/OPERATOR 472 <br /> C thia H. Madrid General Manager, Retail Services <br /> OFFICIAL USE ONLY Permit Number 473 Permit Approved 474 1 Permit Expiration Date 475 <br /> UP FORM(1/2000 Version) 3 Formerly SWRCB Form B <br /> SBC UST-B.doc <br />