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r UNIFIED PROGRAM CONSOLIDATED FORM TANKS UNDERGROUND STORAGE TANKS - TANK PAGE 2 VL PIPING CONSTRUCTION C1ec!all that or_ UNDERGROUND PIPING ABOVEGROUND PIPING SYSTEM TYPE I.PRESSURE [:12.SUCTION ❑3.GRAVITY 451 ❑ I.PRESSURE ❑2. SUCTION ❑3.GRAVITY 459 CONSTRUCTION ❑ I.SINGLE WALL El 3.LINED TRENCH [:]99.OTHER 46° ❑ I.SINGLE WALL ❑95.UNKNOWN 46z MANUFACTURFR [12.DOUBLE WALL ❑95.UNKNOWN [12.DOUBLE WALL ❑99.OTHER MANUFACTURER 461 MANUFACTURER 463 ❑ 1.BARE STEEL [16.FRP COMPATIBLE 111100% MrHANOL [11.BARE STEEL ❑6.FRP COMPATIBLE w/l00%ME-nV NOL ❑2.STAINLESS STEEL [:17.GALVANIZED STEEL ❑Unknown ❑2. STAINLESS STEEL [17.GALVANIZED STEEL ❑3.PLASTIC COMPATTBLE W/CONTENTS ❑99. Otho ❑3. PLASTIC COMPATIBLE W/CONTENTS [19.FLEXIBLE(HDPE) [199. OTHER d.FIBERGLASS ❑S.FLEXIBLE(HDPE) ❑4. FIBERGLASS ❑9.CATHODIC PROTECTION 5.STEEL W/COATTNG ❑9.CATHODIC PROTECTION 464 ❑5. STEEL W/COATTNG ❑95.UNKNOWN 465 VII.PIPING LEAK DETECTION cSecit au that (A tion ortee iao,,momg proInm dull be aubmited to the local agency.) UNDERGROUND PIPING ABOVEGROUND PIPING SINGLE WALL PIPING 466 SINGLE WALL PIPING 467 PRESSURIZED PIPING(Check all that appy): PRESSURIZED PIPING(CI-A.11 that appy): ❑I.ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST W AUTO PUMP SHUT ❑1. ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP OFF FOR LEAK,SYSTEM FAILURE,AND SYSTEM DISCONNECTION+ SHUT 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(O.1GPH) ❑3.ANNUAL INTEGRITY TEST(O.1GPH) ❑4. DAILY VISUAL CHECK CONVENTIONAL SUCTION SYSTEMS CONVENTIONAL SUCTION SYSTEMS(Check.1]thst.ppty) ❑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) GRAVrTY FLOW(Check all that apply) ❑8. DAILY VISUAL MONITORING ❑9. BIENNIAL INTEGRITY TEST(0.1 GPH) SECONDARILY CONTAINED PIPING SECONDARILY CONTAINED PIPING PRESSURIZED PIPING(Check all that appy): PRESSURIZED PIPING(Check all that appy): 10. CONTINUOUS TURBINE SUMP SENSOR W►TH AUDIBLE AND VISUAL 10, CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL ALARMS AND(Check one) ALARMS AND(Check me) ❑a. AUTO PUMP SHUT OFF WHEN A LEAK OCCURS ❑a AUTO PUMP SHUT OFF WHEN A LEAK OCCURS 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 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) ❑ 12. ANNUAL INTEGRITY TEST(0.1 GPH) 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(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)WITHOUT FLOW ❑ 15. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST) SHUT OFF OR RESTRICTION ❑ 16.ANNUAL INTEGRITY TEST(0.1 GPH) ❑ 16.ANNUAL 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 77 DAILY VISUAL CHECK DATE INSTALLED 468 ❑2.CONTINUOUS DISPENSER PAN SENSOR+AUDIBLE AND VISUAL ALARMS ❑5.TRENCH LINER/MONITORING [:13.CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR ❑6.NONE 469 DISPENSER+AUDIBLE AND VISUAL ALARMS DL OWNER/OPERATOR SIGNATURE I ceni(y t io lorvution prwidod herein is true■ acaarate to the beg of my knawiedae. SIGN URE OWNER/OPERA DATE 470 NAM OF O ER/OPRATO (print)) 471 TITLE OFAaWNER/ PERAT 47 � / Q P<rmn Number 1For local uw oaly) 477 P proved(For local use only) 474 Perron Epiratloo Date(For local u nly) 175 UPCF(12/99 revised) 12 Formerly SWRCB Form B