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UNIFIED PROGRAM CONSOLIDATED FORM TANKS UNDERGROUND STORAGE TANKS - TANK PAGE 2 VL PIPING CONSTRUCTION Cheek all that Page_cr_ UNDERGROUND PIPING ABOVEGROUND PIPING SYSTEM TYPE Al.PRESSURE [:12.SUCTION ❑3.GRAVITY 458 ❑ 1.PRESSURE ❑2. SUCTION ❑3.GRAVITY 459 CONSTRUCTION, I.SINGLE WALL [13.LINED TRENCH ❑99.OTHER 46Q ❑1.SINGLE WALL ❑95.UNKNOWN 462 MANUFACTURER 2.DOUBLE WALL ❑95.UNKNOWN ❑2.DOUBLE WALL ❑99.OTHER MAN'UFA'tTURER 461 MANUFACTURER 463 ❑ 1.BARE STEEL ❑6.FRP COMPATIBLE wh00% METHANOL ❑1.BARE STEEL ❑6.FRP COMPATIBLE wn00%MET11ANOL ❑2.STAINLESS STEEL ❑7.GALVANIZED STEEL ❑Unknown ❑2. STAINLESS STEEL ❑7.GALVANIZED STEEL ❑3.PLASTIC COMPATIBLE W/CONTENTS ❑99. Odra ❑3. PLASTIC COMPATIBLE W/CONTENTS ❑8.FLEXIBLE(HDPE) [199. OTHER 4.FIBERGLASS ❑8.FLEXIBLE(HDPE) ❑4. FIBERGLASS ❑9.CATHODIC PROTECTION ❑5.STEEL W/COATING C]9.CATHODIC PROTECTION 464 E]5. STEEL W/COATING ❑95.UNKNOWN 465 VII.PIPING LEAK DETECTION Check all i; (A ort6e monsiorigg progirm.hall be aobmeted to the local. eo UNDERGROUND PIPING ABOVEGROUND PIPING SINGLE WALL PIPING 466 SINGLE WALL PIPING f67 PRESSURIZED PIPING(Check all that apply): PRESSURIZED PIPING(Check■ll that appy): LEAK ETECTOR 3.0 GPM T Wm AUTO ❑ I DOFF OR LEAKS STEM FDETECTOR AI URF,AND SYSTEM DIVSSOiNNECTIOAUTO N+MP Slilfi ❑1. SHUT MO LINE YSDTEM FAILURE,AND.SYST EM DISCONNECTION+ AUDIBLE AND VISUAL ALARMS. AUDIBLE AND VISUAL ALARMS. [12.MONTHLY 0.2 GPM TEST ❑2. MONTHLY 0.2 GPM TEST ❑3.ANNUAL INTEGRITY TEST(0.1 GPM) ❑3.ANNUAL INTEGRITY TEST(0.1GPM) ❑4. DAILY VISUAL CHECK CONVENTIONAL SUCTION SYSTEMS CONVENTIONAL SUCTION SYSTEMS(acct all that appy) ❑5.DAILY VISUAL MONITORING OF PUMPING SYSTEM+TRIENNIAL PIPING ❑5. DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM INTECRIIY TEST(0.1 GPM) SAFE SUCTION SYSTEMS(NO VALUES IN BELOW GROUNDPIPING): ❑6. TRIENNIAL INTEGRITY TEST(0.1 GPM) [17.SELF MONITORING SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): GRAVITY FLOW ❑7. SELF MONITORING ❑9.BIENNIAL INTEGRITY TEST(0.1 GPM) GRAVITY FLOW(Check all that applyp. ❑8. DAILY VISUAL MONITORING ❑9. BIENNIAL INTEGRITY TEST(0.1 GPM) SECONDARILY CONTAINED PIPING SECONDARILY CONTAINED PIPING PRESSURIZED PIPING(Check all that ppy): PRESSURIZED 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 coal ALARMS AND(Chock me) ❑a. AUTO PUMP SHUT OFF WHEN A LEAK OCCURS ❑a AUTO PUMP SHUT OFF WHEN A LEAK OCCURS Xb. 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 ❑c NO AUTO PUMP SHUT OFF XI. AUTOMATIC LINE LEAK DETECTOR(3.0 GPM TEST)WITH FLOW SHUT ❑ I I. AUTOMATIC LEAK DETECTOR OFF OR RESTRICTION ❑ 12. ANNUAL INTEGRITY TEST(0.1 GPM) ❑ 12. ANNUAL INTEGRITY TEST(0.1 GPM) SUCTION/GRAVITY 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(Chocksill 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 GPM TEST)WITHOUT FLOW ❑ 15. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST) SHUT OFF OR RESTRICTION ❑ 16.ANNUAL INTEGRITY TEST(0.1 GPM) ❑16.ANNUAL INTEGRITY TEST(0.1 GPM) ❑ 17. DAILY VISUAL CHECK ❑ 17. DAILY VISUAL CHECK VIII.DISPENSER CONTAINMENT DISPENSER CONTAINMENT ❑ 1.FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE 1.DAILY VISUAL CHECK DATE INSTALLED 468 ❑2.CONTINUOUS DISPENSER PAN SENSOR+AUDIBLE AND VISUAL ALARMS `❑5.TRENCH LINER/MONITORING ❑3.CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR [:16.NONE 469 DISPENSER+AUDIBLE AND VISUAL ALARMS DL OWNER/OPERATOR SIGNATURE 1 tt ify th in( wtioc provided herein u tna me to the beg or my knowledge. SIGNA U E WNER/OPE TOR DATE 470 4 NAME OF O PRATOR(print) 471 TITLE OF 0 R/OP RATO 72 4�2 / 7 P<nnn Number(For local use mly) 473 Permsroved( r kcal use Daly) 474 Permit Ea�int-Dake(For loyal use orl 475 UPCF(12/99 revised) 12 Formerly SWRCB Form B