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r N UNIFIED PROGRAM CONSOLIDATED FORINT TANKS UNDERGROUND STORAGE TANKS -TANK PAGE 2 Page_of_ VI.PIPING CONSTRUCTION check all that acct) UNDERGROUND PIPING ABOVEGROUND PIPING 459 SYSTEM TYPE PRESSURE ❑2.SUCTION ❑3.GRAVITY 453 ❑1.PRESSURE ❑2. SUCTION ❑3.GRAVITY a62 CONSTRUCTION ❑L SINGLE WALL ❑3.LINED TRENCH ❑99.OTHER 460 ❑1.SINGLE WALL ❑95.UNKNOWN DOUBLE WALL ❑95.UNKNOWN MANUFACTURER E32.DOUBLE WALL C199.OTHER MANUFACTURER*J:�. 463 / 461 MANUFACTURER ' w/100% NIETHANOL ❑I.BARE STEEL ❑6.FRP COMPATIBLE W/100%METHANOL 1.BARE STEEL ❑6.FRP COMPATIBLE D STEEL ❑ 7.GALVANIZE Unknown 2. STAINLESS STEEL ❑ ❑2.STAINLESS STEEL ❑7.GALVANIZED STEEL ❑L ❑ [33.PLASTIC COMPATIBLE W/CONTENTS ❑99. Other ❑3. PLASTIC COMPATIBLE W/CONTENTS [38.FLEXIBLE(HDPE) El 99. OTHER 94. 4. FIBERGLASS ❑9.CATHODIC PROTECTION FIBERGLASS ❑S.FLEXIBLE(HDPE) ❑ 465 ❑5.STEEL W/COATING [19.CATHODIC PROTECTION 464 C15. STEEL W�COATING ❑95.UNKNOWN VII.PIPING LEAK DETECTION(Check all that a I)A desert nor..of the monitonn roetam shall be submitted to the local aeenc .) UNDERGROUND PIPING ABOVEGROUND PIPING SINGLE WALL PIPING 466 SINGLE WALL PIPING a67 PRESSURIZED PIPING(Check all that apply): PRESSURIZED PIPING(Check all thatapply): H ALTO PUMP SHUT C11. ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP ❑1.ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WIT OFF FOR LEAK,SYSTEM FAILURE,AND SYSTEM DISCONNECTION+ AUOFAILURE,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(0.1 GPH) El 3.ANNUAL INTEGRITY TEST(O.IGPH) [14. DAILY VISUAL CHECK CONVENTIONAL SUCTION SYSTEMS CONVENTIONAL SUCTION SYSTEMS(Check all that apply) ❑5.DAILY VISUAL MONITORING OF PUMPING SYSTEM+TRIENNIAL PIPING C3 5. DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM INTEGRITY TEST(0.1 GPH) SAFE SUCTION SYSTEMS(NO VALUES IN BELOW GROUNDPIPING): O FE SUCTION SYSTEMS 6. TRIENNIAL I(NO VALVES INTY TEST(0.1 BELOW GROUND PIPING): ❑7.SELF MONITORING [17. SELF MONITORING GRAVITY FLOW GRAVITY FLOW"(Check all that apply): ❑9.BIENNIAL INTEGRITY TEST(0.1 GPH) [18. 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 all that apply): 10. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL 10. CO AR SSO US ND(Check o E)SUMP SENSOR WITH AUDIBLE AND VISUAL L RMS AND(Check one) AUTO PUMP SHUT OFF WHEN A LEAK OCCURS a AUTO PUMP SHUT OFF WHEN A LEAK OCCURS AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM / b AUTO PUMP DISCONNECTION U b OFF FOR LEAKS,SYSTEt FAILURE AND SYSTEM DISCONNECTION ❑c. NO AUTO PUMP SHUT OFF ❑c NO AUTO PUMP SHUT OFF I1. NO LINE LEAK DETECTOR(3.0 GPH TEST)WITH FLOW SHUT �11 AUTOMATIC LEAK DETECTOR OFF OR RESTRICTION C1 12. ANNUAL INTEGRITY TEST(0.1 GPH) ❑12. ANNUAL INTEGRITY TEST(0.1 GPH) SUCTION/GRAVITY SYSTEM SUCTION/GRAVITY SYSTEM 13 ❑13. CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS ❑ . 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 WI H AUTO PU�1P SHUT OFF 14. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF AUDIBLE AND VISUAL ALARMS AUDIBLE AND VISUAL ALARMS [:115. 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 ❑1.FLOAT,MECHANISM THAT SHUTS OFF SHEAR VALVE ❑4.DAILY VISUAL CHECK DATE INSTALLED 468 [3 2.CONTINUOUS DISPENSER PAN SENSOR+AUDIBLE AND VISUAL ALARMS ❑5.TRENCH LINER/MONITORING 469 ONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR ❑6.NONE ISPENSER+AUDIBLE AND VISUAL ALARMS IX.OWNER/OPERATOR SIGNATURE I certify that the�i o t provided herein is true and ac o the best of my knowledge. /DATE 470 ) S►GNATU O ER/O ERA 471 TITLE OF OWNE OPERATOR rx1� NAME OF OPRA R(pr't) 7r l�y /� �( l! 473 Permit Expuat on Date(For local ' only) 475 Permit Number(For local use only) - 473 Permit Approved(For local use only) UPCF(12/99 revised) 12 Formerly SWRCB Form B