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L� UNIFIED PROGRAM CONSOLIDATED FORM TANKS UNDERGROUND STORAGE TANKS - TANK PAGE 2 VI. PIPING CONSTRUCTION Check all that I Pagc 3 of UNDERGROUND PIPING ABOVEGROUND PIPING SYSTEM TYPE ❑ I. PRESSURE ❑ 2. SUCTION MTGRAvrry 458 ❑ 1. PRESSURE 0 2. SUCTION O 3. GRAVITY 459 CONSTRUCTION ❑ I. SINGLE WALL ❑ 3. LINED TRENCH ❑ 99.OTHER 460 ❑ 1. SINGLE WALL ❑ 95. UNKNOWN 462 MANUFACTURER DOUBLE WALL ❑ 95. UNKNOWN ❑ 2. DOUBLE WALL ❑ 99.OTHER MANUFACTURER 461 MANUFACTURER 463 O 1. BARE STEEL ❑ 6. FRP COMPATIBLE w/IW% METHANOL ❑ 1. BARE STEEL ❑ 6. FRP COMPATIBLE W/IOVI.7olHFR OL ❑ 2. STAINLESS STEEL ❑ 7. GALVANIZED STEEL ❑ Uubt wn ❑ 2. STAINLESS STEEL ❑ 7. GALVANIZED STEEL ❑ 3. PLASTIC COMPATIBLE W/ CONTENTS ❑ 99. Odw ❑ 3. PLASTIC COMPATIBLE W/ CONTENTS [19. FLEXIBLE (HDPE) O 99 4: FIBERGLASS ❑ 8. FLEXIBLE (HDPE) ❑ 4. FIBERGLASS ❑ 9. CATHODIC PROTECTION ❑ 5. STEEL W/COATING ❑ 9. CATHODIC PROTECTION 464 ❑ 5. STEEL W/COATING ❑ 95. UNKNOWN 465 VII. PIPING LEAK DETECTION Check all that A ion of the Tp**gpMgram shall be submitted to the local UNDERGROUND PIPING ABOVEGROUND PIPING SINGLE WALL PIPING 466 SINGLE WALL PIPING 467 PRESSURIZED PIPING (Check all that apply): PRESSURIZED PIPING (Cheek all that apply): ❑ 1. ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST AUTO PUMP SHUT ❑ 1. ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST MM 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 (0.IGPM ❑ 3. ANNUAL INTEGRITY TEST (0.IGPM ❑ 4. DAILY VISUAL CHECK CONVENTIONAL SUCTION SYSTEMS CONVENTIONAL 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 PIPINGr GRAVITY FLOW 07. SELF MONITORING ❑ 9. BIENNIAL INTEGRITYTEST(0.1 GPH) GRAVITYFLOW (Check dltlhuapplyx ❑ E. DAILY VISUAL MONITORING ❑ 9. BIENNIAL INTEGRITY TEST (0.1 GPH) SECONDARILY CONTAINED PIPING SECONDARILY CONTAINED PIPING PRESSURIZED PIPING (Chock all that apply): PRESSURIZED PIPING (Check all that apply): 10. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL 10. CONTINUOUS TURBINE SUMP SENSOR= AUDIBLE AND VISUAL A LAP MS AND (Check one) ALARMS AND (Check oat) ❑ 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 DISCONNEC 70N DISCONNECTION ❑c. NO AUTO PUMP SHUT OFF ❑c NO AUTO PUMP SHUT OFF [:111. AUTOMATIC LINE LEAK DETECTOR (3.0 GPH TEST) WITH FLOW SHUT OFF OR RESTRICTION Q 11. AUTOMATIC LEAK DETECTOR ❑ 12. ANNUAL INTEGRITY TEST (0.1 GPH) ❑ 12. ANNUAL INTEGRITY TEST (0.1 GPH) SU�CTION/GRAVITY SYSTEM SUCTIOWGRAVTTY SYSTEM 03' I3. CONTINUOUS SUMP SENSOR + AUDIBLE AND VISUAL ALARMS ❑ 13. CONTINUOUS SUMP SENSOR + AUDIBLE AND VISUAL ALARMS EMERGENCY GENERATORS ONLY (Cheek all that apply) EMERGENCY GENERATORS ONLY (Cheek all that apply) ❑ 14.CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF 4 ❑ 14. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF e AUDIBLE AND VISUAL ALARMS AUDIBLE AND VISUAL ALARMS ❑ 15. AUTOMATIC LINE LEAK DETECTOR (3.0 GPIs TEST) WTITIOCfr FLOW SHUTOFF OR RESTRICTION ❑ 15. AUTOMATIC LINE LEAK DETECTOR (3.0 GPH TEST) ❑ 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 ❑ 4. DAILY VISUAL CHECK DATE INSTALLED 468 ❑ 2. CONTINUOUS DISPENSER PAN SENSOR+AUDIBLE AND VISUAL ALARMS ❑ 5. TRENCH LINER / MONITORING Q / ❑ 3. CONTINUOUS DISPENSER PAN SENSORIW_T[ AUTO SHUT OFF FOR 6. NONE 469 / DISPENSER+ AUDIBLE AND VISUAL ALARMS IX. OWNER/OPERATOR SIGNATURE I certify that the hdomution pmvidW herein is true and aceurate to the best of my knowledge. SIGNATURE OF OWNER/OPERATOR DATE 479 NAME OF OWNER/OPRATOR (print) 471 TITLE OF OWNER/OPERATOR 472 Pcrmit Numbcr (For local use only) 473 Permit Approved (For local we only) 474 Permit Expiration Date (For local use only) 475 UPCF (12/99 revised) Formerly SWRCB Form B