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UNIFIED PROGRAM CONSOLIDATED FORM TANKS UNDERGROUND STORAGE TANKS - TANK PAGE 2 :P •} 'r '�:'5i;:-:;;:;.�_::�t< .. :.:.:... .........::.....:::.. tPING:CONSTRUCiION.(Cheotdmatappy) ::.i;�?y':>�. _ 6. UNDERGROUND PIPING A80VEGROlJNO PIPING SYSTEM TYPE ❑ 1. PRESSURE ❑2 SUCTION ❑3.GRAVITY 458 I❑ 1. PRESSURE ❑2 SUCTION ❑3.CRANKY 459 CONSTRUCTION/ID 1- SINGLE WALL ❑3. LINED TRENCH ❑99.OTHER 4610 (❑ 1. SINGLE VULL ❑95. UNKNOWN 462 MLANUFACTURERI❑ 2- DOUBLE WALL ❑95.UNKNOWN ❑Z. DOUG'c WALL ❑99. OTHER MANUFACTURER 461 MA).UFACTURER 463 ❑ 1.BARE STEEL ❑6. FRP COMPATIBLE Vd IOD%METHANOL ❑ 1. BARE STEEL ❑6- FRP COMPATIBLE VVI 100%METHANOL MATERIALS AND ❑ 2 STAINLESS STEEL ❑ 7.GALVANIZED STEEL ❑2. STAINLESS STEEL ❑ 7. GALVANIZED STEEL CORROSION PROTECTION ❑ 3_ PLASTIC COMPATIBLE WTTN CONTENTS ❑95. UNKNOYM ❑ 3. PLASTIC cowATIBLE wrrH CONTENTS ❑ 8. FLMBLE (HOPE) 1199. OTHER ❑ 4. FIBERGLASS ❑8 FL0a8(.E(HOPE) 1199.OTHER ❑4. FIBERGLASS ❑ 9. CATHODIC PROTECTION ❑ S. STEELYIICOATING ❑9.CATHODIC PROTECTION 464 ❑ S. STEEL YO COATING 095. UNKNO+M1 465 V11.PIPIMGLEA1t--0MCTiON' AcdcastMa r AdewiaSoAclme ram'sAdbe{ir6iidreetameticaJ UNDERGROUND PIPING ABOVEGROUND PIPING SINGLE WALL PIPING 466 SINGLE WALL PIPING .157' PRESSURIZED PIPING CCr>Kk as that apply). - PRESSURIZED PIPING(Check AX that apply): ❑ 1. ELECTRONIC UNE LEAK DETECTOR 3.0 GPM TEST WITH AUTO PUMP SHUT OFF FOR •❑ 1. ELECTRONIC LINE LEAK DETECTOR 3.0 GPM TEST VATH AUTO PUMP SKIT OFF FOR LEAK• LEAK SYSTEM FAILURE.AND SYSTEM DISCONNECTION•AUOI8LE AND VISUAL SYSTEM FAILURE.AND SYSTEM DISCONNECTION•AUDIBLE AND VISUAL ALARMS i ALARMS C] 2- MONTHLY 0 2 GPM TEST 11 2. MONTHLY0.2 GPH TEST ❑ 3 ANNUAL INTEGRITY TEST(0.1 GPM) 7. ANNUAL 1NT'EGRtTY TEST(0.1 GPH) - ❑ 4. DAILY VISUAL CHECK " ::0,VENTONAL SUCTION SYSTEMS. CONVENTIONAL SUCTION SYSTEMS(Chock as that appy): 5 DAILY VISUAL MONITORING OF PUMPING SYSTEM•TRIENN!AL PIPING INT-GR/TY ❑ 5. DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM 1<ST(0.1 GPH) ❑ 6 TRIENNIAL INTEGRITY TEST(0.1 GPH) SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING) SAF-E_SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): 7. SELF MONITORING ❑ 7. SELF MONrroWNG - 1 .cVtIY FLOW .G.2A1.fTY FLOW(Cresk a;T that apply): i 9 B(ENNf?11NTEGRfTY T`tSi(0,1 GPH) :❑ 3 OAILYVISUALf.NONTORINC !❑ 9 BIEN`pL UT'c GRTY TEST(0.1 GPH) SECONDARILY CONTAINED PIPING SECONDARILY CONTAINED PIPING PIPING(Chick ad mat appy)r PAESSURIZ'_0 PIPING(Check as Mat apply/: 1 0 CONTINUOUS TURBINE SUM?SENSOR w(Ty AUDIBLE ANO VISUAL ALARMS AND (Check 10 CON MIRMS TURBINE SUMP SENSOR WITH AU018LE AND VISUAL ALARMS AND(deck one) one) ❑ a. AUTO PUMP SHUT OFF VMEN A LEAK OCCURS ❑ a /.UTO PUMP SHUT OFF VMEN A LEAK OCCURS ❑ b.AUTO PUMP SHUT OFF FOR LEAKS.SYSTEM FAILURE AND SYSTEM I ❑b. AUTO PUMP SHUT OFF FOR LEAKS.SYSTEM FARURE AND SYSTEM DISCONNECTION I OISCONNECTION ❑c NO AUTO PUMP SHUT OFF ( ❑c NO AUTO PUFAP SHUT OFF 7 11 AUTOMATIC LINE LEAK DETECTOR(1.0 GPH TEST)WTH FLOP!SHUT OF=OR .❑ 11.AUTON tTIC LEAK DETECTOR ! RESTRICTION ❑ 12.ANNUAL INTEGRITY TEST(0.1 GPH) ❑ 12. ANNUAL INTEGRITY TEST(0.1 GPH) SUCnONNGRAVfTY SYSTEM. 'S'JC110 VG;V VFTY SYSTEM: ❑ 13 CONANUOUS SUMP SENSOR•AUDIBLE AND VISUAL ALARMS ❑ 13. CONTiM)OVS SUMP SENSOR•AUDIBLE AND VISUAL ALARMS EMERGENCY GENERATORS ONLY(Check ad Nat appy) EMERGENCY GENERATORS ONLY(Check a4 that apply) J 14. CONTINUOUS SUMP SENSOR VyfTttT AUTO PUMP SHUT OFF•AUDIBLE AND :❑ 14. COt.TIN000S SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF•AUDIBLE AND VISUAL VISUAL ALARMS ALA2115 0 15.AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)1MTTi�FLOW SHUT OFF OR ❑ 1S.AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST) RESTRICTION ❑ 16. ANNUAL INTEGRITY TEST(0.1 GPH) )❑ 16.ANNUAL INTEGRITY TEST(0.1 Gpm ❑ 17. DAILY VISUAL CHECK I❑ 17.DAILY VISUAL CHECK VUL uspENSER CONTAJNR{FXT.:::; ri i i:.:•E,`:rs c DISPENSER CONTAINMENT ❑ I. FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE ❑4. DAILY VISUAL CHECK DATE INSTALLED 468 ❑ 2 CONTINUOUS DISPENSER PAN SENSOR•ADDIBLE AND VISUAL ALAR.NS ❑S.TRENCH LINER I MONITORING ❑ 3. CONTINUOUS DISPENSER PAN SENSOR MH AUTO SHUT OFF FOR DISPENSER•AUDIBLE AND VISUAL ALARMS ❑6.NONE 469 ;...., - /..)L OWNERJOPERATORSIGNATURE:: %:'.<;??` E I cenXy that 91e i'larmatiOn provl0ad best Amy Iv+or4eCye- SIGNATUREOF PE T R I DATE ' 470 NAMEOF OWNER OPERATOR(PAM) 471 0= ,ERNOPE ®R 472 �itvu k�ydo e-a Pcrtni[NtaMer(For bca!use ONy) 471 I Penn4 ApptoveQ(Fpr bca/tae orJ).1 474-1 Pum4 EAp7ation Date(Far boat nu onW 415 I JPCF(1/99 revised) 7 Forrnerty SWRCB Forrn B