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A . 7 all 1 111-101, UNIFIED PROGRAM CONSOLIDA'T'ED FORM TANKS UNDERGROUND STORAGE TANKS-TANK PAGE 2 VI.PIPING CONSTRUCTION(Check a0 that I) Page of UNDERGROUND PIPING ABOVEGROUND PIPING SYSTEM TYPE 1.PRESSURE ❑2.SUCTION Q 3.GRAVITY 453 ❑I.PRESSURE ❑2. SUCTION ❑3.GRAVITY 459 CONSTRUCTION ❑1.SINGLE WALL ❑3.LINED TRENCH ❑99.OTHER 460 ❑1.SINGLE WALL ❑95.UNKNOWN 462 hLANUEALTURER 02.DOUBLE WALL Q 95.UZJKNOWN ❑2.DOUBLE WALL ❑99.OTHER MANUFACTURER dyJ 461 MANUFACTURER 463 ❑1.BARE STEEL Q 6,FRP CojgPATIBLE r:'i o-. METHANOL ❑1.BARE STEEL ❑6.FRP COMPATIBLE WAN%METHANOL Q 2.STAINLESS STEEL 0 7.GALVANIZED STEEL ❑Lratknomt ❑2. STAINLESS STEEL ❑7.GALVANIZED STEEL Q 3.PLASTIC COMPATIBLE W/CONTENTS ❑99 Other [13. PLASTIC COMPATIBLE W/CONTENTS ❑S.FLE.�UBLE(HDPE) Q 99, OTHER 4.FIBERGLASS ❑S.FLEXIBLE(HDPE) El4.FIBERGLASS ❑9.CATHODIC PROTECTION Im ❑5.STEEL W/COATING [39.CATHODIC PROTECTION 464 Q 5. STEEL W/COATING ❑45.UNKNOWN 465 VII.PIPING LEMS:DETECTION(Check.11 Umt a tv)(.A desc tion of the Alombnnag peEatu shall be soteuitted to the local agency) UNDERGROUND PIPING ABOVEGROUND PIPING SINGLE WALL PIPING 466 SINGLE WALL PIPING 46 PRESSURIZED PIPING(Check all that apply): PRESSURIZED PIPING(Clock all that apply): ❑1.ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST R TTH AUTO PUhIP SI4UT [11.ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP OFF FOR LEAK,SYSTEM FAILURE,AND SYSTEM DISCONNECTION+ SHUT OFF FOR LEAK,SYSMIF.AII.URRE.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(O.IGPH) Q 3.ANNUAL INTEGRITY TEST(O.1GPH) ❑4. DAILY VISUAL CHECK CONVENTIONAL SUCTION SYSTEMS CONVENTIONAL SUCTION SYSTEMS(Clock 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): Q 6. TRIENNIAL INTEGRITY TEST(0.1 GPH) [17.SELF MONITORING SAFE SUCTION SYSTEMS(ATO VALVES IN BELOW GROUND PIPING): GRAVITY FLOW ❑7. SELF MONITORING ❑9.BIENNIAL INTEGRITY TEST(0.1 GPH) GRAVITY FLOW(Cheekalldotapply): Q S.DAILY VISUAL MONITORING [19. BIENNIAL INTEGRITY TEST(0.1 GPH) SECONDARILY CONTAINED PIPING SECONDARILY CONTAINED PIPING PRESSURIZED PIPING(Check all that apply): PRESSURIZED PIPING(Clock all that apply): 10. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL 10. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL ALARMS AND(Check one) ALARMS AND(Check ow) ❑a. AUTO PUMP SHUT OFF WHEN A LEAK OCCURS Q a AUTO PUMP SHUT OFF WHEN A LEAK OCCURS Kb. AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM ❑It AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM DISCONNECTION DISCONNECTION ❑c. NO AUTO PUMP S14UT OFF Qc NO AUTO PUMP SHUT OFF 11. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)WITH FLOW SHUT ❑11 AUTOMATIC LEAK DETECTOR OFF OR RESTRICTION ❑12. ANNUAL INTEGRITY TEST(0.1 GPH) Q 12. ANNUAL INTEGRITY TEST(0.1 OPH) SUCTION/GRAVITY SYSTEM SUCTION/GRAVITY SYSTEM ❑13. CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS Q 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 k ❑14. AUDIBLE AND VISUAL PSE AOARMS WITHOUT AUTO PUMP SHUT OFF' AUDIBLE AND VISUAL ALARMS ❑15. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)WITHOUT FLOW ❑15. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST) SHUT OFF OR RESTRICTION ❑16.ANNUAL INTEGRITY TEST(0.1 GPH) ❑16.ANNUAL INTEGRITY TEST(0.1 GPH) ❑17. DAILY VISUAL CHECK 1 ❑17. DAILY VISUAL CHECK VIIL 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 �3.CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR ❑6.NONE 469 DIDISPENSERa_tDrs + T LE AND VISUAL ALARMS IX.OWNER/OPERATOR SIGNATURE I attify that the inf area laovided herein is true and accurate e� my knowkd8e. 4'0 SIGNATM 0 WNER/O BATOR DATE ^ i NAME F OW OP ATOR ) 4 1 TITLE F OWN4uppli TOR ; y t filj ` 473 Petmit Approved or local we only) 474 Penult]Tspiration Date(For local n e only) 4"5 Peimi[Ntmtber(Far local naso eery) PPfO R' UPCF(12/99 revised) 12 Formerly SWRCB Form D