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Abe UNIFIED PROGRAM CONSOLIDATED FORM TANKS I UNDERGROUND STORAGE TANKS -TANK PAGE 2 L�- VI.PIPING CONSTRUCTION(Check alf that appal UNDERGROUND PIPING ABOVEGROUND PIPING SYSTEM TYPE ❑ 1 PRESSURE ❑ 2. SUCTION ❑ 3. GRAVITY ❑ 1. PRESSURE ❑ 2. SUCTION ❑ 3. GRAVITY CONSTRUCTION/ ❑ 1. SINGLE WALL ❑ 3. LINED TRENCH ❑99. OTHER ❑ i. SINGLE WALL ❑95. UNKNOWN MANUFACTURER ❑ 2_ DOUBLE WALL 1:195 UNKNOWN ❑ 2. DOUBLE WALL ❑99. OTHER MANUFACTURER MANUFACTURER ❑ i.BARE STEEL ❑ 8. FRP COMPATIBLE WI 100%METHANOL ❑ 1. BARE STEEL ❑ 8. FRP COMPATIBLE WI 100%METHANOL MATERIALS AND ❑ 2, STAINLESS STEEL ❑ 7.GALVANIZED STEEL ❑ 2. STAINLESS STEEL ❑ 7. GALVANIZED STEEL CORROSION PROTECTION ❑ 3. PLASTIC COMPATIBLE WITH CONTENTS ❑95. UNKNOWN ❑ 3. PLASTIC COMPATIBLE WITH CONTENTS ❑ B. FLEXIBLE(HDPE) ❑99. OTHER ❑ 4. FIBERGLASS ❑ S. FLEXIBLE(HDPE) ❑99. OTHER, ❑ 4. FIBERGLASS ❑ 9. CATHODIC PROTECTION ❑ 5. STEEL W/COATING ❑ 9. CATHODIC PROTECTION ❑ 5. STEEL W/COATING ❑95. UNKNOWN VII.PIPING LEAK DETECTION(Cheek all that appy) UNDERGROUND PIPING ABOVEGROUNO PIPING SINGLE WALL PIPING SINGLE WALL PIPING - PRESSURIZED PIPING(Check as that appy): PRESSURIZED PIPING(Check all that apply): ❑ 1. ELECTRONIC LINE LEAK DETECTOR 3.0 GPM TEST WITH AUTO PUMP SHUT OFF FOR ❑ 1. ELECTRONIC LINE LEAK DETECTOR 3.0 GPM TEST WITH AUTO PUMP SHUT OFF FOR LEAK, LEAK,SYSTEM FAILUPE.AND SYSTEM DISCONNECTION+AUDIBLE AND VISUAL SYSTEM FAILURE,AND SYSTEM DISCONNECTION;AUDIBLE AND VISUAL ALARMS ALARMS ❑ 2. MONTHLY 0.2 GPM TEST ❑ 2. MONTHLY 0 2 GPM TEST ❑ 3. ANNUAL INTEGRITY TEST(0.1 GPM) ❑ 3. ANNUAL INTEGRITY TEST(0.1 GPM) 0.4. DAILY VISUAL CHECK CONVENTIONAL SUCTION SYSTEMS: CONVENTIONAL SUCTION SYSTEMS(Check all that appy): ❑ 5. DAILY VISUAL MONITORING OF PUMPING SYSTEM+TRIENNIAL PIPING INTEGRITY ❑ 5. DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM TEST(0 1 GPM) ❑ 8. TRIENNIAL INTEGRITY TEST(0.1 GPM) SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): ❑ 7. SELF MONITORING ❑ 7. SELF MONITORING GRAVITY FLOW: GRAVITY FLOW(Check all that apply): ❑ 9. BIENNIAL INTEGRITY TEST(0.1 GPM) ❑ B. DAILY VISUAL MONITORING ❑ 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 WITH AUDIBLE AND VISUAL ALARMS AND 10.CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL ALARMS AND check one (Check one) 1 ) ❑ 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 ❑ C. NO AUTO PUMP SHUT OFF ❑ i t. AUTOMATIC LINE LEAK DETECTOR(3.0 GPM TEST)WITH FLOW SHUT OFF OR ❑ 11. AUTOMATIC LEAK DETECTOR RESTRICTION ❑ 12. ANNUAL INTEGRITY TEST(0.1 GPM) ❑ 12. ANNUAL INTEGRITY TEST(0.1 GPM) SUCTIONIGRAVITY SYSTEM: SUCTIONIGRAVITY SYSTEM: ❑ 13. CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS ❑ 13. CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS EMERGENCY GENERATORS ONLY(Check all that appy) EMERGENCY GENERATORS ONLY(Check all that apply) ❑ 14. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF+AUDIBLE AND ❑ 14. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF+AUDIBLE AND VISUAL VISUAL ALARMS ALARMS ❑ 15. AUTOMATIC LINE LEAK DETECTOR(3.0 GPM TEST)WITHOUT FLOW SHUT OFF OR ❑ 15. AUTOMATIC LINE LEAK DETECTOR(3.0 GPM TEST) RESTRICTION ❑ 18. ANNUAL INTEGRITY TEST(0.1 GPM) ❑ 18. 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 ❑ 4. DAILY VISUAL CHECK DATE INSTALLED ❑ 2. CONTINUOUS DISPENSER PAN SENSOR+AUDIBLE AND VISUAL ALARMS ❑ 5. TRENCH LINER/MONITORING ❑ 3. CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR DISPENSER+AUDIBLE AND VISUAL ALARMS ❑ 8. NONE IX.OWNER/OPERATOR SIGNATURE 1 certify that the informatwn provided herein is We and accurate to Na best of my knowledge. SIGNATURE OF OWNER/OPERATOR DATE NAME OF OWNER'OPERATOR rpant) TITLE OF OWNERIOPERATOR Permit Number(For local use only) Permit Approved(For I use only) 1 _ Permit Expiration Date(For local use only) �� CUPAFORM(4199) • Formerly SWRCB Form B