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06/11/2004 14:44 209-836630 PAGE 04 <br /> UNIFIER PROGRAM CO`SOILIAATD FORM TANKS <br /> UNDERGROUND ST®/1S.t GE RL',>,®ll S-'TANK PAIGE q 6 <br /> Y1•PHpINIG CONSTRU 10N Cheokalttkat i t ABOVEGROUND PIPING <br /> UNDERGROUND PIPING 3 GRAVITY a59 <br /> 3.GRAVITY d55 ❑I.PRESSURE Q 2.SUCTION a' a6z <br /> SYSI VA TYPE 1.PRESSURE D 3 st)cnDN ❑ 460 Q 1 SINGLE WALL C]95.UNKNOWNOTHER <br /> COVSTRut:T10N Q 1.SINGLE WALL C']3.LINEDTItENGH ❑99.OTHER 2 DOUBLE WALL ®99.OTHER 40 <br /> MANUFACTU R�'2.DOUBLE WALL ❑95.UNKNOWN 461 MANUFACTURER <br /> MANUFACTURER C1IRER D 6.FRP COMPATIBLE W/I I ETRANOL <br /> Ell,BARE STEEL ❑6.FRP COMPATIBLE w/lOw- ]Unknown <br /> ETHANOL ®1.SARI STEEL D 7,GALVANIZED STEEL <br /> Q 2.STAINLESS STEEL D 7.GALVANIZED STEEL ©99. other <br /> Q 2. STAINLESS STEEL <br /> ®3.PLASTIC COMPATIBLE WI CONTENTS Q 99. Othef ❑3.PLASTIC COMPATIBLE Wt CONTENTS ❑b.FLt3XiBLk.(HDPE) ®99.OTHER <br /> Q a.FIBERGLASS ©9,CATHODIC PROTECTION ass <br /> a,FIBERGLASS Q a.FLEXIBLE(HDPE) Q 46a Cl S. 95.UNKNOWN <br /> STEEL W/COATING <br /> 5.STEEL W/COATING ®9.CATHODIC PROT!CTION ABOVEGROUND PIPING <br /> ed <br /> YHI.PIPItiC LEATE <br /> K DECTION Ch-1k sll thu A aescri boa of ate motsittvt o 10ehaA ne eaWu ILOUw the)oed 467 <br /> UNDERGROUND PIPING 466 SLNGLE WALL PIPING <br /> SINGLE WALL PIPING PRESSURIZED PIPING(Cheek all that W00 <br /> TEST MM AUTO PUMP <br /> PRESSURIZED PIPING(C9taFk all that app1Y7. <br /> SHUT OFF FOR LEAK.SYS'TE'M FAILURE,AND SYSTEM DISCONNECTION <br /> ®1.ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP SHUT ❑I• E3-ECTRONSC LINE LEAK DETECTOR 3.0 GPH <br /> OFF FOR LEAK.SYSTEM FAILURE.AND SYSTEM DISCONNECTION AUDIBLE AND VISUAL ALARMS' <br /> AUDIBLE AND VISUAL ALARMS. ®2. MONTHLY 0-2 GPM TEST <br /> 0 2,MONTHLY o.a GpH TEST 3 ANNUAL INTEGRITY TEST(0-IGP14) <br /> ®3.ANNUAL INTEGRITY TEST(0.1 GPH) ©4, DAILY VISUAL CHECK <br /> CONVENTIONAL SUCTION SYSTEMS(Chm dtt'"Pty) <br /> CONVENTIONAL SUCTION SYSTEMS <br /> ®3, DAILY VISUAL MONITORING OF PIPING AND PUMPING SYS <br /> TEM <br /> ❑5•DAILY VISUAL MONITORING OF PUMPING SYSTEM*T(UENNIAL PIPING <br /> INTEGRITY TEST(0.1 GPH) ®b. TRIENNIAL INTEGRITY TEST(0.1 GPH) <br /> SAFE SUCTION SYSTEMS(NO VALUES[N BELOW GROUNDPIP0IG): <br /> SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPINGfi <br /> Q 7.SELF MONITORING_ D 7, SELF MONITORING <br /> GRAVITY FLOW ORAVITY FLOW(Cheek all that appty): <br /> 9.BIENNIAL INTEGRITY TEST(0.1 GPH) ( Q S•DAILY VISUAL MONITORING <br /> ®9. BIENNIAL INTEGRITY TEST(0.1 GPH) <br /> SECONI)A1tILY CONTAINED PIPING <br /> SECONDARILY CONTAI d>D PIPING 1 ` <br /> PRESSURIZED PIPING(Check mithe tOP'yY AUDIBLE AND VISUAL <br /> PRESSURIZED PIPING(Check'!!that"Ply) H AUDIBLE AND VISUAL 10. CONTINUOUS TURBINE SUMP SENSOR�+1TH <br /> 10. CONTINUOUS TURBTNE SUMP SENSOR W I ALARMS AND iCheck oae> <br /> ALARMS AND(cheek ase) ®a AUTO PUMP SHUT'OFF WHEN A LEAK OCCURS <br /> �}a. AUTO PUMP SHUT OFF WHEN A LEAK OCCURS <br /> SYSTEM FAILURE AND SYSTEM ❑4 Ap�00�T�EC7 ON OFF FOR LEAKS,SYSTEM FAILURE AND SY , <br /> Ej 6. AUTO PUMP SHUT OFF FOR LEAKS, <br /> DISCONNECTION ❑c NO AUTO Pum?SHUT OFF <br /> ©e. NO AUTO PUMP SHUT OFF <br /> FLOW SHUT 011. AUTOMATIC LEAK DETECTOR <br /> ®(( OFF OR RESTRICTION- AUTOMATIC LINE DETECTOR(3.o GPH TEST)W�J3i <br /> Q 12. ANNUAL INTEGRITY TEST(0.1 GPH) ®12. ANNUAL INTEGRITY TEST(0.1 GPH) <br /> SUCTION/GRAVITY SYSTEM <br /> SUCTIONIGRAVITY SYSTEM 13. CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS <br /> ©13. CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS Q EMERGENCY GINRRATORg ONLY(Cheek all" q*) <br /> EMERGENCY GENERATORS ONLY(Check an that apply) <br /> Q 14.CONTINUOUS SUMP SENSOR�AUTO PUMP SHUT OFF• ❑14.CONTINUOUSBLA STJMP SENSOR} TH4UI AUTO PUMP EMIT OFF <br /> AUDIBLE AND visuAL ALARMS <br /> AUDIBLE AND VISUAL ALARMS ( LEAK DETECTOR(3.0 GPH TEST) <br /> n 15. AUTOMATSMr1 OFF IC INE LEAK DDETECTOR(3.0 GPH TEST)3IalllSIiLT FLOW 15. AUTOMATIC LINE L <br /> ❑16.ANNUAL INTEGRITY TEST(0.1 GPH) <br /> ®16.ANNUAL INTEGRITY TEST(0.1 GPH) ®17. DAILY VISUAL CHECK <br /> Q 17. DAILY VISUAL CHECK <br /> VIII.DHSPEIYS£R COYTA110ENT ` <br /> ®4DAILY VISUAL CHECK I <br /> DISPENSER CONTAINMENT Q 1.FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE . t <br /> DATE INSTALLED 46s Q 2.CONTINUOUS DISPENSER PAN SENSOR+AUDIBLE AND VISUAL ALARMS Q S.TRENCH LINER MONIT '10,419 <br /> N r469 <br /> � <br /> CONTINUOUS DISPENSER PAN SENSOR W�AUTO SHUT OFF FOR ©6.NONE <br /> DISPENSER,.AUDIBLE AND VISUAL ALARMS { <br /> IX.OWNEWOPERATOR SIGNATURE r <br /> nmin is true aoa a mmw w the beat of mY kaowtedg►. <br /> I catNty dut dse Ivfutxalioa provided DATE <br /> SIGNATURE OF OWNERIOPERATOR <br /> apt TITLE OF OWNER/OPEAATOR�w�e� <br /> ptAME OF OWNER/OPRATOP(print) 475 <br /> Pa Ioea1 vee otdy) 473 Pamut pppro•ta(Pa Iocal tete only) <br /> :474 Pemrtk ExImmuoa 1 tFoe toeal eae qtly) <br /> t>arsmt Nates l <br /> UPCF(!2199 revised) <br /> !2 Formerly SWRCS Form B <br />