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rn UNIFIED PROGRAM CONSOL DATED FORM TANKS UNDERGROUND STORAGE T NKS - TANK PAGE 2 VI.PIPING CONSTRUCTION(Chcck all th 1) Page d aP UNDERGROUND PIPING ABOVEGROUND PIPING SYSTEM TYPE ® I.PRESSURE ❑2.SUCTION ❑3.GRAVITY 453 [111.PRESSURE ❑2. SUCTION ❑3.GRAVITY 459 CONSTRUCTION ❑ 1.SINGLE WALL ❑3.LINED TRENCH [199,OTHER 46o ❑ j.SINGLE WALL ❑95.UNKNOWN 462 MANUFACTURER ®2.DOUBLE WALL [195.UNKNOWN ❑ .DOUBLE WALL [:199.OTHER MANUFACTURER Smith Fiberglass 461 MANUFACTURER 463 ❑ 1.BARE STEEL ❑6.FRP COMPATIBLE W/160% METH&NOL [11.BARE STEEL ❑6.FRP COMPATIBLE W1100%METHANOL Cl 2.STAINLESS STEEL [17.GALVANIZED STEEL ❑Unknown ❑2. STAINLESS STEEL ❑7.GALVANIZED STEEL ❑3.PLASTIC COMPATIBLE W/CONTENTS ❑99. Other ©3. PLASTIC COM ATIBLE W/CONTENTS ❑8.FLEXIBLE(HDPE) [199, OTHER ®4.FIBERGLASS ❑B.FLEXIBLE(HDPE) ❑4. FIBERGLASS [-19.CATHODIC PROTECTION ❑5.STEEL W/COATING [19.CATHODIC PROTECTION 464 ❑5. STEEL W/COA 17ING ❑95.UNKNOWN 465 VII.PIPING LEAK DETECTION(Check all that=Ply)(A dtscription oft Lc monitorin program shall be submitted to the local eocy.) UNDERGROUND PIPING ABOVEGROUND PIPING SINGLE WALL PIPING 466 SINGLE WALL PIPING 467 PRESSURIZED PIPING(Check all that apply): PRFSSUI JZFD PIPING(Check all that apply): ❑ 1.ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP SHUT ❑1. ELECTRONIC LINE LEAK DETECTOR 3.0 GFH TEST WITH AUTO PUMP OFF FOR LEAK,SYSTEM FAILURE,AND SYSTEM DISCONNECTION+ SHjT OFF FOR LEAK,SYSTEM FAILURE,AND SYSTEM DISCONNECTION+ AUDIBLE AND VISUAL ALARMS. AUDIBLE AND VISUAL ALARMS. ❑2.MONTHLY 0.2 GPH TEST ❑2. MONTHLY 0.2 GPH TEST ❑3.ANNUAL INTEGRITY TEST(0.IGPH) ❑3.AxIqUAL INTEGRITY TEST(O.IGPH) [14. D LY VISUAL CHECK CONVENTIONAL SUCTION SYSTEMS CONN , IONAL SUCTION SYSTEMS(Check all that apply) ❑5.DAILY VISUAL MONITORING OF PUMPING SYSTEM+TRIENNIAL PIPING ❑5. DAILY 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) ❑7.SELF MONITORING SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): GRAVITY FLOW ❑7. SELF MONITORING ❑9.BIENNIAL INTEGRITY TEST(0.1 GPH) GRAY FLOW(Check alt that apply): ❑8. D LY VISUAL MONITORING ❑9. BIENNIAL INTEGRITY TEST(0.1 GPH) SECONDARILY CONTAINED PIPING SECONDARILY CONTAINED PIPING PRESSURIZED PIPING(Check all that apply): PRESSU UZED PIPING(Check all that apply): I0. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL 10. CO OUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL ALARMS AND(Cheek one) AIJ AM S 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 ❑c. NO AUTO PUMP SHUT OFF Or NO AUTO PUMP SHUT OFF ®11. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)WITH FLOW SHUT Cl 11. AUTOMATIC LEAK DETECTOR OFF OR RESTRICTION ®12. ANNUAL INTEGRITY TEST(0.1 GPH) C1 12. ANNUAL INTEGRITY TEST(0.1 GPH) - SUCTION/GRAVITY SYSTEM SUCTION/GRAVITY SYSTEM ❑13. CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS ❑13. qONTFNUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS EMERGENCY GENERATORS ONLY(Check all that apply) EMERGENCY GENERATORS ONLY(Check all that apply) ❑14. CONTINUOUS SUMP SENSOR WITHQ AUTO PUMP SHUT OFF• ❑14. ONNTIINUOAUSSSUMP SSE ALARMS w HQ AUTO PUMP SHUT OFF# AUDIBLE AND VISUAL ALARMS AUDIBLE ❑15. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)WITHOUT FLOW ❑15, UTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST) SHUT OFF OR RESTRICTION Cl 16.ANNUAL INTEGRITY TEST(0.l GPH) ❑16. AL INTEGRITY TEST(0.1 GPH) ❑ 17, DAILY VISUAL CHECK ❑17. DAILY VISUAL CHECK VIII.DISPENSER CONTAINMENT DISPENSER CONTAINMENT ❑1.FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE ❑4.DAILY VISUAL CHECK DATE INSTALLED 469 ❑2.CONTINUOUS DISPENSER PAN SENSOR+AUDIBLE AND VISUAL ALARMS [15.TRENCH LINER/MONITORING ®3.DISPENSER E E AND VISUAL CONTINUOUS DISPENSER WITH AUTOS UT OFF FOR C16.NONE 469 2403 IX.OWNER/OPERATOR S GNATURE I certify that the information provided herein is true and accurate to the best of my knowIcdge. SIGN E OF OWN OP RATO DATE 470 hp✓ t-!J, NAME WNER/OPRATO (print) 471 TITLE F OWNER/OPERATOR 47' �� - Permit Number(For local use only) 473 Permit Approved(For local use only) 474 Perrtut Expiration Date(For local use oniy) 475 UPCF (12199 revised) 12 Formerly SWRCB Forin 3