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r UNIFIED PROGRAM CONSOLIDATED FORM TANKS UNDERGROUND STORAGE TANKS-TANK PAGE 2 ABOVEGROUND PIPING UNDERGROUND PIPING SYSTEM TYPE ❑ 1 PRESSURE 2. SUCTION ❑ 3. GRAVITY ❑ 1. PRESSURE ❑ 2.SUCTION ❑ 3. GRAVITY CONSTRUCTION/ ��❑ff 1. SINGLE WALL 3. LINED TRENCH ❑99. OTHER ❑ 1. SINGLE WALL ❑95. UNKNOWN MANUFACTURER UQ 2. DOUBLE WALL ❑95. UNKNOWN ❑ 2. DOUBLE WALL ❑99.OTHER MANUFACTURER MANUFACTURER ❑ 1.BARE STEEL ❑ 6. FRP COMPATIBLE W/100%METHANOL ❑ 1.BARE STEEL ❑ 6. FRP COMPATIBLE W/100%METHANOL MATERIALS AND ❑ 2. STAINLESS STEEL ❑ 7. GALVANIZED STEEL ❑2. STAINLESS STEEL ❑ 7.GALVANIZED STEEL CORROSION PROTECTION 11 3. PLASTIC COMPATIBLE WITH CONTENTS ❑95. UNKNOWN ❑ 3. PLASTIC COMPATIBLE WITH CONTENTS ❑ S. FLEXIBLE(HDPE) C ❑99.OTHER 4. FIBERGLASS ❑ S. FLEXIBLE(HDPE) ❑99. OTHER ❑ 4. FIBERGLASS ❑ 9. CATHODIC PROTECTION ro 5 STEEL W/COATING ❑ 9 CATHODIC PROTECTION ❑ 5 STEEL W/COATING ❑95 UNKNOWN PIPIN(3�EAKGE'b'hGjFON(Cheoka�Uratep 7 �.,. UNDERGROUND PIPING - ABOVEGROUND PIPING SINGLE WALL PIPING SINGLE WALL PIPING PRESSURIZED PIPING(Check all that apply): PRESSURIZED PIPING(Check all that apply): - ❑ 1. ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP SHUT OFF FOR ❑ 1. ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP SHUTOFF FOR LEAK, LEAK,SYSTEM FAILURE,AND SYSTEM DISCONNECTION+AUDIBLE AND VISUAL SYSTEM FAILURE,AND SYSTEM DISCONNECTION;-AUDIBLE AND VISUAL ALARMS . ALARMS ❑ 2.MONTHLY 0.2 GPH TEST - ❑ 2. MONTHLY 0.2 GPH TEST ❑ 3.ANNUAL INTEGRITY TEST(0.1 GPH) ❑ 3.ANNUAL INTEGRITY TEST(0.1 GPH) ❑ 4. DAILY VISUAL CHECK CONVENTIONAL SUCTION SYSTEMS(Check all that apply): - CONVENTIONAL SUCTION SYSTEMS: - - ❑ 5. DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM C15. DAILY VISUAL MONITORING OF PUMPING SYSTEM+TRIENNIAL PIPING INTEGRITY - TEST(0.1 GPH) ❑ 6. TRIENNIAL INTEGRITY TEST(0.1 GPH) 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 GPH) ❑ 8..DAILY VISUAL MONITORING _ ❑ 9. BIENNIAL INTEGRITY TEST(0.1 GPH) - SECONDARILY CONTAINED PIPING SECONDARILY CONTAINED PIPING - - PRESSURIZED PIPING(Check all that apply): PRESSURIZED PIPING(Check aq 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) ❑ 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 Elc. NO AUTO PUMP SHUT OFF ❑ c. NO AUTO PUMP SMUT OFF - - ❑ 11. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)WITH FLOW SHUT OFF OR ❑ 11.AUTOMATIC LEAK DETECTOR RESTRICTION - ❑ 12. ANNUAL INTEGRITY TEST(0.1 GPH) ❑ 12:ANNUAL INTEGRITY TEST(0.1 GPH) STION/GRAVITY SYSTEM: SUCTION/GRAVITYSYSTEM: 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+AUDIBLE AND ❑ 14.CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF+AUDIBLE AND,VISUAL VISUAL ALARMS ALARMS ❑ 15.AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)WRHOUT FLOW SHUT OFF OR .❑ 15.AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST) RESTRICTION ❑ 16.ANNUAL INTEGRITY TEST(0.1 GPH) 1 ❑ 16.ANNUAL INTEGRITY TEST(0.1 GPH) ❑ 17. DAILY VISUAL CHECK 1017. DAILY VISUAL CHECK VHF I)19PEttt GOF4AINMC�FI s, 4 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 6. NONE OL OWNERIOPERATOR SIGNATURE I certify that the information provided herein is to to the best of my knowledge_ SIGNAT OF ER/O RATO DATE A Z- NA OWNER/OPERATOR(pd t) CB S�I TITLE OF OOPE O R n (a E J 79rmilumber(For local use only) Permit Approved(For local use only) Permit Expiration Date(Forlocal use only) CUPAFORM(4/99) Formerly SWRCB Form B