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UNIFIED PROGRAM CONS O LIDATED F OR TANKS EELUNDERGROUND STORAGE TANKS - TANK PAGE 2 �4 o VI.PIPING CONSTRUCTION(Checka01/wt apply) ABOVEGROUND PIPING UNDERGROUND PIPING ❑ 2. SUCTION ❑ 3. GRAVITY SYSTEM TYPE ❑ 1 PRESSURE 19 2. SUCTION 11 3. GRAVITY ❑ 1. PRESSURE ❑95. UNKNOVM IONI ❑ 1. SINGLE WALL ❑ 3. LINEDTRENCH ❑99. OTHER ❑ 1. SINGLE WALL 2. DOUBLE WALL [199. OTHER MANUFACTURER ❑ MARER ❑2. DOUBLE WALL ❑95. UNKNOWN MANUFACTURER MANUFACTURER 1. BARESTEEL [3S. FRP COMPATIBLE WI 100%METHANOL [11.BARE STEEL ❑ e. FRP COMPATIBLE WI 100%METHANOL 0 2. STAINLESS STEEL ❑T. GALVANIZED STEEL MAERIALS AND ❑ 2. STAINLESSSTEEL ❑ T. GALVANIZEDSTEEL ❑99. OTHER CORROSION ❑ 3 PLASTIC COMPATIBLE WITH CONTENTS ❑95. UNKNOWN ❑ 3. PLASTIC COMPATIBLE WITH CONTENTS 0 9, CATHODIC PROTECTION PROTECTION 4. FIBERGLASS ❑ 8. FLEXIBLE(HDPE) [199. OTHER 4. FIBERGLASS ❑ ❑ 5. STEELWICOATING (395, UNKNOWN ❑ 5. STEEL W/COATING ❑ 9. CATHODIC PROTECTIONVII.PIPING LEAK DETECTION(Check al that apply) - ABOVEGROUND PIPING UNDERGROUND PIPING SINGLE WALL PIPING SINGLE WALLPIPING PRESSURIZED PIPING(Check all that apPIY): PRESSURIZED OIPING(Check all that apply): SYSTEM FAILURE,ANDSYSTEMOR3oOECTION AUDIBLE AND VISUAL ALARMS ❑ 1 LEAN?SYO141C LINE LEAK STEM FAILURE,DETECTOR 3.0 GPH TEST WITH AUTO PUMP SHUT OFF EM DISCONNECTION 4 AUDIBLE AND VISUAL SYSTEM ❑ 1. ELECTRONIC LINE LEAK DETECTOR BO GPH TEST WITH AUTO PUMP SHUT OFF FOR ❑ 2. MONTHLY 0.2 GPM TEST ALARMS ❑ 2. MONTHLY 02 GPM TEST ❑ 3.ANNUAL INTEGRITY TEST(0.1 GPM) ❑ 3. ANNUAL INTEGRITY TEST(01 GPM) ❑ 4. DAILY VISUAL CHECK CONVENTIONAL SUCTION SYSTEMS(Ghack NI fhat apply): CONVENTIONAL SUCTION SYSTEMS: ❑ S. DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM ❑ 5. DAILY VISUAL MONITORING OF PUMPING SYSTEM.TRIENNIAL PIPING INTEGRITY ❑ B. TRIENNIAL INTEGRITY TEST(01 GPM) TEST(0.1 GPM) SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): WE SUCTION SELF MONITORING VALVES IN BELOW GROUND PIPING): ❑ T. SELF MONITORING GRAVITY FLOW(Chock all Mat DRAW: GRAVITY FLOW ❑ 9. BIENNIAL INTEGRITY TEST III 1 GPM) ❑ e. DMNNIALILY INTEGRITY TEST ❑ 9. BIENNIAL INTEGRITY TEST(0.1 GPM) SECONDARILY CONTAINED PIPING SECONDARILY CONTAINED PIPING PRESSURIZED PIPING(Check all that apply): PRESSURIZED PIPING(Check all that apply): 10. CONTINUOUS TURBINE SUMP SENSOR WTH AUDIBLE AND VISUAL ALARMS AND 10.CONTINUOUS TURBINE SUMP SENSOR HATH AUDIBLE AND VISUAL ALARMS AND(rheG ono) (Check one) ❑ a.AUTO PUMP SHUT OFF WHEN A LEAK OCCURS ❑ a. AUTO PUMP SHUT OFFWHEN A LEAK OCCURS ❑ b. AUTO PUMP SHUT OFF FOR LEAKS.SYSTEM FAILURE AND SYSTEM ❑ b.AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM DISCONNECTION DISCONNECTION ❑ c. NOAUTOPUMPSHUTOFF ❑ o NOAUTO PUMP SHUT OFF ❑ 11 AUTOMATIC L NE LEAK DETECTOR(3.0 GPM TEST)WITH FLOW SHUT OFF OR ❑ 11. AUTOMATIC LEAK DETECTOR ❑ 12. ANNUAL INTEGRITY TEST(0.1 GPM) ❑ 12. ANNUAL INTEGRITY TEST to 1 GPM) SUGTIONIGRAVITY$.STEM'. SUCTIONIGRAVITY SYSTEM: ❑ ❑ 13. CO 13. CONTINUOUS SUMP SENSOR.AUDIBLE AND VISUAL ALARMS CONTINUOUS SUMP SENSOR�AUgBLE AND VISUALAURMS EMERGENCY GENERATORS ONLY(Check ell that ePWY) EMERGENCY GENERATORS ONLY(Check al Mat appy Cl 14. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF+AUDIBLE AND ❑ 14. CONTINUOUS SUMP SENSOR TURNOUT AUTO PUMP SHUT OFF•AUDIBLE AND VISUAL ALARMS VISUALALARMS ❑ 15. AUTOMATIC UNE LEAK DETECTOR(3.0 GPM TEST)WITHOUT FLOW SHUT OFF OR ❑ 15. AUTOMATIC UNE LEAK DETECTpi(30 WH TEST) RESTRICTION ❑ 1e. ANNUAL INTEGRITY TEST(0.1 GPM) ❑ 18. ANNUAL INTEGRITY TEST(0.1 GPM) ❑ 12. DAILY VISUAL CHECK ❑ 17. DAILY VISUAL CHECK VUL DISPENSER CONTAINMENT DISPENSER CONTAINMENT ❑ 1. FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE ❑ 4. DAILY VISUAL CHECK DATE INSTALLED ❑ 2. CONTINUOUS DISPENSER PAN SENSOR a AUDIBLE AND VISUAL ALARMS ❑ 5. TRENCH LINER I MONINORMG ❑ 3. CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR DISPENSER�AUDIBLE AND VISUAL ALARMS ❑ 6. NONE 1A.OWNER/OPERATOR SIGNATURE I certify dial Ne inhrmation provided 1lamin is hue and acwmla to the ben of my knavdedge. SIGNATUREOFO E U R NAME OF OWNE O TOR(Odnq TITLE OF ONMEHJUI`oRATOR LL) )Y.l Penni)Expinnion Date(ForWal use only) Pelmif Numbat(Forlmal uxs only) Permit Approved(Forlocal use only) CUPAFORM(4199) Formerly SWRCB Form