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UNIFIED PROGRAM CONSO ID=FORM TAINKS UNDERGROUND STORAGE rf ANKS - TANK PAGE 2 VI.PIPING CONSTRUCTION(Check all az I) Page of. i UNDERGROUND PIPING ABOVEGROUND PIPING SYSTEM TYPE ® 1.PRESSURE• ❑2.SUCTION ❑3.GRAVITY 459 1.PRESSURE ❑2. SUCTION ❑3.GRAVITY 459 CONSTRUCTION ❑1.SINGLE WALL ❑3.LINED TRENCH [199.OTHER 460 1,SINGLE WALL [195,UNKNOWN 462 MANUFACTURER ®2.DOUBLE WALL ❑95.UNKNOWN 2.DOUBLE WALL ❑99.OTHER MANUFACTURER _ Smith Fiberglass 461 MANUFACTURER 463 ❑1.BARE STEEL [16.FRP COMPATIBLE w/100% METHANOL ❑ 1.BARE STEEL ❑6.FRP COMPATIBLE Wf100y METHANOL ❑2.STAINLESS STEEL ❑7.GALVANIZED STEEL ❑Uttknovm ❑2. STAINLESS STEEL ❑7.GALVANIZED STEEL ❑3.PLASTIC COMPATIBLE W/CONTENTS [199. Other ❑3. PLASTIC Cot APATIBLF WI CONTENTS ❑S.FLEXIBLE(HDPE) ❑99. OTHER N 4.FIBERGLASS ❑S.FLEXIBLE(HDPE) [:14. FIBERGLAS ❑9.CATHODIC PROTECTION ❑5.STEEL W/COATING ❑9.CATHODIC PROTECTION 464 ❑S. STEEL W/CO TING ❑95.UNKNOWN 465 VII.PIPING LEAK DETECTION(Check alt thatapply)(A dacri lion o the monitoring program shall be submitted to the local enc .) UNDERGROUND PIPING ABOVEGROUND PIPING SINGLE WALL PIPING 466 SINGLE WALL PIPING 467 PRESSURIZED PIPING(Check all that apply): PRESSI.RIZED PIPING(Check all that apply): ❑1.ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP SHUT ❑ 1. E ECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP OFF FOR LEAK,SYSTEM FAILURE,AND SYSTEM DISCONNECTION+ SJUT OFF FOR LEAK,SYSTEM FAILURE,AND SYSTEM DISCONNECTION+ AUDIBLE AND VISUAL ALARMS. A JD1BLE AND VISUAL ALARMS. ❑2.MONTHLY 0.2 GPH TEST [12. ONTHLY 0.2 GPH TEST ❑3.ANNUAL INTEGRITY TEST(0.(GPH) [:13. AL INTEGRITY TEST(0.1GPH) ❑4. DAILY VISUAL CHECK CONVENTIONAL SUCTION SYSTEMS CONVENTIONAL SUCTION SYSTEMS(Check all that apply) [� S.DAILY VISUAL MONITORING OF PUMPING SYSTEM+TRIENNIAL PIPING ❑5 IC AILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM INTEGRITY TEST(0.1 GPH) SAFE SUCTION SYSTEMS(NO VALUES IN BELOW GROUNDPIPING): ❑6. TRIENNIAL INTEGRITY TEST(0.1 GPH) [17.SELF MONITORING SAFES CTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): GRAVITY FLOW ❑7. SELF MONITORING ❑9.BIENNIAL INTEGRITY TEST(0.1 GPH) GRAVI FY FLOW(Check all that apply): ❑ S. DAILY VISUAL MONITORING ❑9. F IENNIAL INTEGRITY TEST(0.1 GPH} SECONDARILY CONTAINED PIPING SECONDARILY CONTAINED PIPING PRESSURIZED PIPING(Check all that apply): PRESSI JRIZED PIPING(Check all that apply): 10. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL 10, CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL ALARMS AND(Check one) AI ARMS AND(Check one) (]a. AUTO PUMP SHUT OFF WHEN A LEAK OCCURS ❑a AUTO PUMP SHUT OFF WHEN 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 Qc. NO AUTO PUMP SHUT OFF Cle NO AUTO PUMP SHUT OFF ®11. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)WITH FLOW SHUT []11. AUTOMATIC LEAK DETECTOR OFF OR RESTRICTION ®12. ANNUAL INTEGRITY TEST(0.1 GPH) [112. ANNUAL INTEGRITY TEST(0.1 GPH) SUCTIONIGRAVITY SYSTEM SUCTION/GRAVITY SYSTEM ❑13. CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS ❑13. CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS EMERGENCY GENERATORS ONLY(Check all that apply) EMERGENCY GENERATORS ONLY(Check all that apply) ❑14. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF ❑ 14. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF" AUDIBLE AND VISUAL ALARMS AUDIBLE AND VISUAL ALARMS ❑15. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)WITM FLOW [] 15. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST) SHUT OFF OR RESTRICTION ❑16.ANNUAL INTEGRITY TEST(0.1 GPH) ❑16. kNNUAL INTEGRITY TEST(0.1 GPH) ❑17. DAILY VISUAL CHECK ❑ 17. DAILY VISUAL CHECK VIII.DISPENSER CONT NMENT DISPENSER CONTAINMENT ❑ 1.FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE ❑4.DAILY VISUAL CHECK DATE INSTALLED 468 ❑2.CONTINUOUS DISPENSER PAIN SENSOR+AUDIBLE A D VISUAL ALARMS ❑5.TRENCH LINER I MONITORING 2Q03 ®3.CONTINUOUS DISPENSER PAN SENSOR WITH AUTO HUT OFF FOR ❑6.NONE 469 DISPENSER+AUDIBLE AND VISUAL ALARMS IX.OWNER/OPERATOR IGNATURE I certify that the information provided herein is true and accurate 10 the best of my knowledge. SIGNA £OF WNER/OP BATOR DATE 470 O /�7, 4, NAM OWNER/OPRATOR(print) 03 471 T[TL OF OWNER/OPERATOR 472 Permit Number(For lou][LSC Only) 473 Permit Approved(For local use only} 474 Permit Expiration Date{For local use only) 475 UPCF(12199 revised) 12 Formerly SWRCB Form B