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v' • od J(h� to 4 UNIFIED PROGRAM CONSOLIDATED FORM TANKS UNDERGROUND STORAGE TANKS-TANK PAGE 2 IT PIPING CONSTRUCTION i. --aR that m Page of UNDERGROUND PIPING ABOVEGROUND PIPING SYSTEM TYPE X L PRESSURE ❑2.SUCTION ❑3.GRAVITY 458 ❑1.PRESSURE ❑2. SUCTION [13.GRAVITY 459 CONSTRUCTION [11.SINGLE WALL ❑3.LINED TRENCH [199.OTHER 460 ❑1.SINGLE WALL ❑95.UNKNOWN 462 hLA7UEaCTURER jAr2.DOUBLE WALL ❑95. KNOWN [12.DOUBLE WALL ❑99.OTHER MANUFACTURER �I A 461 MANUFACTURER 463 [11.BARE STEEL ❑6 FRP COMPATIBLE n 100.. I TILaNOL [11.BARE STEEL ❑6.FRP COMPATIBLE W/100%METHANOL [12.STAINLESS STEEL ❑7.GALVANIZED STEEL ❑I-T bio«u [12. STAINLESS STEEL ❑7.GALVANIZED STEEL ❑3.PLASTIC COMPATIBLE W/CONTENTS ❑99 Other [13- PLASTIC COMPATIBLE W/CONTENTS ❑8 FLES7BLE(HDPE) ❑99. OTHER X4.FIBERGLASS ❑8.FLEXIBLE(HDPE) ❑4. FIBERGLASS ❑9.CATHODIC PROTECTION ❑5.STEEL W/COATING [19.CATHODIC PROTECTION 464 ❑5. STEEL W/COATING ❑95.UNKNOWN 465 VIL PIPING LEAK DETECTION(Neck au that 1)(.a deet ouofthemautoumgprogm shall be mb4 tied to the local a envy l UNDERGROUND PIPING ABOVEGROUND PIPING SINGLE WALL PIPING 466 SINGLE WALL PIPING 46' PRESSURIZED PIPING(Check all that apply): PRESSURIZED PIPING(Check all that apply): ❑1 ELECTRONIC LINE LEAK DETECTOR 3 0 GPH TEST N,%TH AUTO Pump sBur ❑1. ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP OFF FOR LEAK,SYSTEM FAILURE,AND SYSTEM DISCONNECTION+ SHUT OFF FOR LEAK,SYSTMIFAII.URE,AND SYSTM I DISCONNECHON+ 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) ❑3.ANNUAL INTEGRITY TEST(O.iGPH) ❑4. DAILY VISUAL CHECK CONVENTIONAL SUCTION SYSTEMS CONVENTIONAL SUCTION SYSTEMS(Check allthatapply) [:15.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 PIPING): GRAVITY FLOW ❑7. SELF MONITORING ❑9.BIENNIAL INTEGRITY TEST(0.1 GPH) GRAVITY FLOW(Check all that apply): ❑8. DAILY VISUAL MONITORING [19. BIENNIAL INTEGRITY TEST(0.1 GPH) SECONDARILY CONTAINED PIPING SECONDARILY CONTAINED PIPING PRESSURIZED PIPING(Check all that apply): PRESSURIZED PIPING(Check allthat 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 one) ❑a. AUTO PUMP SHUT OFF WHEN A LEAK OCCURS ❑a AUTO PUMP SHUT OFF WHEN A LEAK OCCURS Vb. AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM ❑b AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM DISCONNECTION DISCONNECTION ❑c. NO AUTO PUMP SHUT OFF ❑c 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) ❑12. ANNUAL INTEGRITY TEST(0.1 GPH) SUCTION/GRAVITY SYSTEM SUCTION/GRAVITY SYSTEM ❑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• ❑14. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF AUDIBLE AND VISUAL ALARMS 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 ❑17. DAILY VISUAL CHECK VIII.DISPENSER CONTAINMENT DISPENSER CONTAINMENT [11.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 V3.CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR ❑6.NONE 469 DISPENSER+AUDIBLE AND VISUGU ALARMS UL OWNERIOPERATOR SIGNATURE I certify that the mf anon provided herein is true std accf.the beat of my knowWp. S11ATiJ$$ Of TOR 470 Vw• NAMY,OF OWN R/ PRATO ( --at) t 4-1 TITLE OF O ER/OPERAT R 472 ivir - Y / Permit Number(For local use only) 473 Permit Approved(For local we only) 474 Pmut Espaxatiun Date(Fan local we acyl 4'S UPCF(12/99 revised) 12 Formerly SWRCB Form B