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_- - ,I UNIFIED PROGRAM CONSOLIDATED FORM TANKS UNDERGROUND STORAGE TANKS -TANK PAGE 2 VL PIPING CONSTRUCTION{Check all Mat apply) ABOVEGROUND PIPING UNDERGROUND PIPING ❑ 2. SUCTION El 3. GRAVITY SYSTEM TYPE ❑ 1 PRESSURE 2. SUCTION ❑ 3. GRAVITY ❑ 1. PRESSURE ❑95. UNKNOWN 1. SINGLE WALL ❑ 3. LINED TRENCH ❑99 OTHER ❑ 1. SINGLE WALL ❑gg OTHER HI CONSTRUCTIOW ❑95. UNKNOWN ❑ 2 DOUBLE WALL MANUFACTURER ❑ 2. DOUBLE WALL MANUFACTURER ❑ e. FRP COMPATIBLE WI WO%METHANOL MANUFACTURER fa1,BARE STEEL ❑ e. FRP COMPATIBLE WI 100%METHANOL ❑ 1. BARE STEEL ❑ T GALVANIZED STEEL ❑ 2. STAINLESS STEEL ❑9g.OTHER MATERIALS AND ❑ 2. STAINLESS STEEL ❑ T.GALVANIZED STEEL ❑95. UNKNOWN ❑ 3. PLASTIC COMPATIBLE WITH CONTENTS ❑ e. FLEXIBLE(HDPE) CORROSION ❑ 3 RUSTIC COMPATIBLE WITH CONTENTS ❑ q. FIBERGLASS ❑ 9. CATHODIC PROTECTION PROTECTION ❑ 0. FLEXIBLE(HDPE) ❑99. OTHER ❑95. UNKNOWN ❑ 4. FIBERGLASS ❑ 5. STEELWICOATING ❑ 5. STEEL W COATING [19. CATHODIC PROTECTI NI.PIPING LEAK DETECTION(Check afl met eppM kEOVEGROUNO PIPING PING UNDERGROUND PIPING SINGLE WALL PI SINGLE WALL PIPING PRESSURIZED PIPING(Check as that applYF PRESSURIZED PIP ING(LAackailmateppM ❑ 1. ELECTRONIC UNE LEAK DETECTOR 3.0 GPM TEST WITHAUTOAND VISUAL SALALARFOR LEAK, SYSTEM FAILURE.AND SYSTEM DISCONNECTION AUDIBLE ANO VISUAL ALARMS I❑ i ELECTRONICLINE LEAK DETECTOR 3a GPM SYSTEM FAILURE,AND SYSTEM DISCONNECTIION+AUDBLE AND VISUALTH AUTO PUMP SHUT OFF FOR ❑ 2 MONTHLY 01 GPM TEST LEAKALARMS ❑ 3. ANNUAL INTEGRITY TEST(0.1 GPM) ❑ 2. MONTHLY 0.2GPH TEST ❑ q DAILY VISUAL CHECK ❑ 3. ANNUAL INTEGRITY TEST JOA GPM) CONVENTIONAL SUCTION SYSTEMS(Check ell that apply): CONVENTIONAL SUCTION SYSTEMS: ❑ 5. DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM ,a 5. DAILY VISUAL MONITORING OF PUMPING SYSTEM+TRIENNIAL PIPING INTEGRITY ❑ 8 TRIENNIAL INTEGRITY TEST(0 1 GPM) TEST(0.1 GPM) SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING)'. SAFE SUCTION SYSTEMS IND VALVES IN BELOW GROUND PIPING): ❑ T. SELF MONITORING ❑ T. SELF MONITORING GRAVITY FLOW(Check all fhet apply): GRAVITY FLOW: ❑ 8. DAILY VISUAL MONITORING ❑ 9. BIENNIAL INTEGRITY TEST(01 GPM) ❑ 9, BIENNIAL INTEGRITY TEST(0.1 GPM) � G SECONDARILY CONTAINED PIPING SECONDARILY CONTAINED PIPING R, PRESSURIZED PIPING(Chack all mal apply): PRESSURIZED PIPING(Chack all that apply) T 10.CONTINUOUS TURBINE SUMP SENSOR`MTH AUDIBLE AND VISUAL ALARMS AND(check anal 10. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL ALARMS AND ❑ e.AUTO PUMP SHUT OFF WHEN A LEAK OCCURS e. AUTO PUMP SHUT OFF WHEN A LEAK OCCURS b.p AUTO PUMP SHUT OFF FOR LEAKS.SYSTEM FAILURE AND SYSTEM ❑ c. NOTOLEAKS.SYSTEM FAILURE AND SYSTEM DISCONNECTION AUTO PUMPS UT OFF0. DISCONNECTION ❑ c. NO AUTO PUMP SHUT OFF ❑ 11. AUTOMATIC LINE LEAK DETECTOR(3.0 GPM TEST)WITH FLOW SMUT OFF OR ❑ 12 ANNUAL INTEGRITYEITTEST(0A GPM) RESTRICTION ❑ 12. ANNUAL INTEGRITY TEST(0 1 GPM) SUCTIONIGRAVITY SYSTEM'. SUCTIONVGRAVITY SYSTEM: [113.CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS C313. CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS EMERGENCY GENERATORS ONLY(Chack aX Mat appy9 EMERGENCY GENERATORS ONLY(Check as that apply) ❑ 14. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF+AUDIBLE AND ❑ 14. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SUTOFF+AUDIBLE AND VISUAL AL-ARMS VISUALALARMS ❑ 15, AUTOMATIC LINE LEAK DETECTOR J3 GPM TEST)WITHOUT FLOW SHUT OFF OR ❑ 15. AUTOMATIC UNE LEAK DETECTOR(3.0 GPM TE RESTRICTION ❑ 18. ANNUAL INTEGRITY TEST Al GPM) ❑ 18. ANNUAL INTEGRITY TEST(0.1 GPM) ❑ 17. DAILYVISUAL CHECK ❑ 9. DAILYVISUAL CHECK VIII.DISPENSER CONTAINMENT ❑ 4. DAILY VISUAL CHECK DISPENSER CONTAINMENT ❑ 1. FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE ❑ 5. TRENCH LINER I MONITORING DATE INSTALLED ❑ 2. CONTINUOUS DISPENSER PAN SENSOR+AUDIBLE AND VISUAL ALARMS ❑ 3.CONTINUOUS DISPENSER PAN SENSOR WTH AUTO SHUT OFF FOR DISPENSER+AUDIBLE AND VISUAL ALARMS . NONE UL OWNEPJOPERATOR SIGNATURE I comfy Mat Me miamlation proNdad herein is tme stud a burete m Me bast at my FnoMed9s. GATE SIGNATURE OF OWNEWOPERATOR I Jo h E F r EOF OWNEWOPERATOR NAME.OF OVNERIOPERATOR WIMP ParmN ExPlratlan Date(Forlocal use anIY1 Permd Number(Forlacel use only) Pemlit Approved(Farbcal use only) • FormeflY SWRCB Form B CUPAFORM(4199)