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UNIFIED PROGRAM CONSOLIDATED FORM ' TANKS UNDERGROUND STORAGE,TANKS-TANK PAGE 2 UNDERGROUND PIPING VI.PIPING CONSTRUCTION(Check adthat appto ge of SYSTEM TYPEABOVEGROUND PIPING 1. PRESSURE ❑ 2. SUCTION ❑ 3. GRAVITY ❑ 1. PRESSURE ❑ i SINGLE WALL ❑ 3. LINED TRENCH ❑ 2. SUCTION ❑ 3. GRAVITY CONSTRUCTION! ❑99 OTHER ❑ 1. SINGLE WALL ❑95. UNKNOWN MANUFACTURER DOUBLE WALL ❑95. UNKNOWN ❑ 2. DOUBLE WALL ❑99. OTHER MANUFACTURER MANUFACTURER ❑ 1.BARE STEEL ❑ 8. FRP COMPATIBLE W/100%METHANOL ❑ 1. BARE STEEL MATERIALS AND ❑ 2. STAINLESS STEEL ❑ 7. GALVANIZED STEEL ❑ 8. FRP COMPATIBLE WI 100%METHANOL CORROSION ❑ 2. STAINLESS STEEL ❑ 7. GALVANIZED STEEL PROTECTION ❑ 3. PLASTIC COMPATIBLE WITH CONTENTS ❑95. UNKNOWN ❑3. PLASTIC COMPATIBLE WITH CONTENTS ❑ B. FLEXIBLE(HDPE) ❑99. OTHER ❑ 4. FIBERGLASS ❑ 8. FLEXIBLE(HOPE) ❑99. OTHER. ❑ 4. FIBERGLASS ❑ 5. STEEL W/COATING ❑ 9. CATHODIC PROTECTION ❑ 9. CATHODIC PROTECTION ❑ S. STEEL W/COATING 095, UNKNOWN ' VII.PIPING LEAK DETECTION(Check alt that appy) UNDERGROUND PIPING SINGLE WALL PIPING ABOVEGROUND PIPING PRESSURIZED PIPING(Check eN that appy): PRESSURIZED PIPING(Cheek all that apply): SWGLE WALL PIPING ❑ 1. ELECTRONIC LINE LEAK DETECTOR 3.0 GPM TEST WITH AUTO PUMP SHUT OFF FOR LEAK,SYSTEM FAILURE.AND SYSTEM DISCONNECTION-AUDIBLE AND VISUAL ❑ 1 ELECTRONIC LINE LEAK DETECTOR 3.0 GPM TEST WITH AUTO PUMP SMUT OFF FOR LEAK. ALARMS SYSTEM FAILURE,AND SYSTEM DISCONNECTION a AUDIBLE AND VISUAL ALARMS ❑ 2. \MONTHLY 0 2 GPM 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: CONVENTIONAL SUCTION SYSTEMS(Check all that appy): ❑ 5 DAILY VISUAL MONITORING OF PUMPING SYSTEM-TRIENNIAL PIPING INTEGRITY ❑ S. DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM TEST(0 1 GPM) SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING)' 11 8, TRIENNIAL INTEGRITY TEST(0.1 GPM) ❑ 7. SELF MONITORING SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): GRAVITY FLOW: 117. SELF MONITORING ❑ 9. BIENNIAL INTEGRITY TEST(0.1 GPM) GRAVITY FLOW(Check all that apply)r ❑ 8. DAILY VISUAL MONITORING ❑ 9 BIENNIAL INTEGRITY TEST(0.1 GPM) SECONDARILY CONTAINED PIPING PRESSUPIZEO PIPING lCneck ak that apply): SECONDARILY CONTAINED PIPING 10. CONTINUOUS TUR81PIE SUMP SENSOR WITH AUDIBLE AND VISUAL ALARMS AND PRESSURIZED PIPING(Cheek alt that appy): (Check one) 10.CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL ALARMS AND(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 DISCONNECTION ❑ b.AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM DISCONNECTION ❑ C. NO AUTO PUMP SHUT OFF 11C. NO AUTO PUMP SHUT OFF ❑ It AUTOMATIC LINE LEAK DETECTOR(3.0 GPM TEST)WITH FLOW SHUT OFF OR RESTRICTION ❑ 11 AUTOMATIC LEAK DETECTOR ❑ 12 ANNUAL INTEGRITY TEST(0.1 GPM) ❑ 12. ANNUAL INTEGRITY TEST(0.1 GRH) SUCTION:GRAVITY SYSTEM SUCTIONIGRAVITY SYSTEM: ❑ 13 CONTINUOUS SUMP SENSOR.AUDIBLE AND VISUAL ALARMS ❑ 13. CONTINUOUS SUMP SENSOR r AUDIBLE AND VISUAL ALARMS EMERGENCY GENERATORS ONLY(Check all that apply) ❑ 14. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF a AUDIBLE AND EMERGENCY GENERATORS ONLY(Check all that apply) VISUAL ALARMS ❑ 14.CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF.AUDIBLE AND VISUAL ❑ ALARMS 15. AUTOMATIC LINE LEAK DETECTOR(3.0 GPM TEST)WITHOUT FLOW SHUT OFF OR RESTRICTION ❑ t5. AUTOMATIC LINE LEAK DETECTOR(3.0 GPM TEST) ❑ 18. ANNUAL INTEGRITY TEST(0.1 GPM) ❑ 18. ANNUAL INTEGRITY TEST(0.1 GPM) ❑ 17. DAILY VISUAL CHECK ❑ 17, DAILY VISUAL CHECK VIII.DISPENSER CONTAINMENT DISPENSER CONTAINMENT ❑ 1. FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE DATE INSTALLED 112. CONTINUOUS DISPENSER PAN SENSOR.AUDIBLE AND VISUAL ALARMS t4. DAILY VISUAL CHECK 5.❑ 3. CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR DISPENSER-AUDIBLE AND VISUAL ALARMS 118. NONE CH LINER/MONITORING I candy Nat the information provided herein is true and accurate to the best of my knowtedge.X OWNER/OPERATOR SIGNATURE SIGNATURE OF OWNE VOPERATOR OaTE NAME OF OWNER/OPERATOR(pnntJ TITLE OF OWNERtOPERATOR Permit Number(For Iota!vee onyJ Permit Approved(Forkxaf use only) Permit Expiration Date(For Iota!use onyJ CUPAFORM(4/99) Formerly SWRCB Form B