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UNIFIED PROGRAM CONSOLIDATED FORM TANKS UNDERGROUND STORAGE TANKS-TANK PAGE 2 of VI.PIPING CONSTRUCTION(Check ad that apply) UNDERGROUND PIPING ABOVEGROUND PIPING SYSTEM TYPE PRESSURE ❑ 2. SUCTION ❑ 3. GRAVITY ❑ 1. PRESSURE ❑ 2. SUCTION ❑ 3. GRAVITY CONSTRUCTION/ ❑ 1. SINGLE WALL ❑ 3. LINED TRENCH ❑99. OTHER ❑ 1. SINGLE WALL [195. UNKNOWN MANUFACTURER 2, DOUBLE WALL ❑95. UNKNOWN ❑ 2. DOUBLE WALL ❑99. OTHER M NUFACTURER MANUFACTURER ❑ 1,BARE STEEL ❑ 6. FRP COMPATIBLE W1 100%METHANOL ❑ 1. BARE STEEL ❑ 6. FRP COMPATIBLEW1 100%METHANOL MATERIALS AND ❑ 2. STAINLESS STEEL ❑ 7. GALVANIZED STEEL ❑ 2. STAINLESS STEEL ❑ 7. GALVANIZED STEEL CORROSION ❑99. OTHER PROTECTION ❑ 3. PLASTIC COMPATIBLE WITH CONTENTS ❑95. UNKNOWN ❑ 3. PLASTIC COMPATIBLE WITH CONTENTS ❑ 8. FLEXIBLE(HDPE) 4. FIBERGLASS ❑ 8. FLEXIBLE(HDPE) [199, OTHER ❑ 4. FIBERGLASS ❑ 9. CATHODIC PROTECTION ❑ 5. STEEL W/COATING ❑ 9. CATHODIC PROTECTION ❑ 5. STEEL WI COATING ❑95. UNKNOWN VII.PIPING LEAK DETECTION(Checka9thetapp/y) UNDERGROUND PIPING ABOVEGROUND PIPING SINGLE WALL PIPINGSINGLE WALL PIPING ' PRESSURIZED PIPING(Check all that apply): PRESSURIZED PIPING(Check all that apply): ❑ 1. ELECTRONIC LINE LEAK DETECTOR 3.0 GPM TEST WITH AUTO PUMP SHUT OFF FOR ❑ 1. ELECTRONIC LINE LEAK DETECTOR 3.0 GPM TEST WITH AUTO PUMP SHUT OFF 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 GPM TEST ❑ 3. ANNUAL INTEGRITY TEST(0.1 GPM) ❑ 3. ANNUAL INTEGRITY TEST(0.1 GPM) ❑ 4. DAILY VISUAL CHECK CONVENTIONAL SUCTION SYSTEMS(Check all that apply): CONVENTIONAL SUCTION SYSTEMS: ❑ 5. DAILY VISUAL MONITORING OF PUMPING SYSTEM-TRIENNIAL PIPING INTEGRITY ❑ 5. DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM TEST(0.1 GPM) ❑ 6. TRIENNIAL INTEGRITY TEST(0.1 GPM) 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 GPM) ❑ 8. DAILY VISUAL MONITORING ❑ 9. BIENNIAL INTEGRITY TEST(0.1 GPM) SECONDARILY CONTAINED PIPING SECONDARILY CONTAINED PIPING PRESSURIZED PIPING(Check all that apply)' PRESSURIZED PIPING(Check all 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 SMUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM DISCONNECTION DISCONNECTION ❑ c. NO AUTO PUMP SMUT OFF ❑ c. NO AUTO PUMP SHUTOFF i t. AUTOMATIC LINE LEAK DETECTOR(3.0 GPM TEST)WITH FLOW SHUT OFF OR ❑ 111, AUTOMATIC LEAK DETECTOR RESTRICTION ❑ 12. ANNUAL INTEGRITY TEST(0.1 GPM) C112.ANNUAL INTEGRITY TEST(0.1 GPM) 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 ad 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 GPM TEST)WITHOUT FLOW SHUT OFF OR ❑ 15. AUTOMATIC LINE LEAK DETECTOR(3.0 GPM TEST) RESTRICTION ❑ 16.ANNUAL INTEGRITY TEST(0.1 GPM) ❑ 16.ANNUAL INTEGRITY TEST(0.1 GPM) ❑ 17. DAILY VISUAL CHECK ❑ 17. DAILY VISUAL CHECK VUL DISPENSER CONTAINMENT, 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 . CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR DISPENSER+AUDIBLE AND VISUAL ALARMS ❑ 6. NONE IX.OWNER/OPERATOR SIGNATURE I certity that the information provided herein is true and accurate to the best of my knowledge. SIGNATURE OF OWNER/OPERATOR DATE NAME OF OWNER/OPERATOR(print) TITLE OF OWNER/OPERATOR Permit Number(For local use only) Permit Approved(For kcal use onw Permit Expiration Date(For local use only) CUPAFORM(4199) Formerly SWRCB Form B