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' S UNIFIED PROGRAM CONSOLIDATED FORM TANKS UNDERGROUND STORAGE TANKS -TANK PAGE 2 Page_of_ VI.PIPING CONSTRUCTION Check all that a Iv) UNDERGROUND PIPING ABOVEGROUND PIPING .PRESSURE ❑2.SUCTION ❑3.GRAVITY 458 ❑1.PRESSURE ❑2. SUCTION El 3.GRAVITY �9 SYSTEM TYPE 1.SINGLE WALL E]95.UNKNOWN CONSTRUCTION I.SINGLE WALL El 3.LINED TRENCH ❑99.OTHER 460 ❑ ❑2.DOUBLE WALL ❑99.OTHER M ,WAFACTURE 2.DOUBLE WALL ❑95.UNKNOWN NIANUFACTURER 463 MAN ACTURER a61 ❑1.BARE STEEL ❑6.FRP COMPATIBLE w/100% NtETHANOL ❑L BARE STEEL ❑6.FRP COMPATIBLE w/100%METHANOL ❑2.STAINLESS STEEL ❑7.GALVANIZED STEEL ❑Unknown ❑2. STAINLESS STEEL ❑7.GALVANIZED STEEL 0}3.PLASTIC COMPATIBLE W/CONTENTS ❑99. Other ❑3. PLASTIC COMPATIBLE VV/CONTENTS ❑8.FLEXIBLE(HDPE) [199. OTHER 4.FIBERGLASS ❑8.FLEXIBLE(HDPE) ❑4. FIBERGLASS ❑9.CATHODIC PROTECTION F-1 5.STEEL W/CORTING ❑9.CATHODIC PROTECTION ❑ aha S. STEEL W/COATING ❑95.UNKNOWN •65 DETECTION(Chick all that a I)(.4 dcscri tion of the monitorin ro¢run shall be submitted to the local aenc -) VII.PIPING LEAK UNDERGROUND PIPING ABOVEGROUND PIPING WALL PIPING 466 SINGLE WALL PIPING i67 SINGLE PRESSURIZED PIPING(Check all that apply): PRESSURIZED PIPING(Check all that apply): ELECRONIC LINE LEAK ETECTOR WITH AUTO PUMP ❑1,ELECTRONIC LINE LEAK DETECTR 3.0 GPH TEST WITH OFF FOR LEAK, YSTEM FAILURE,AND SYSTEM DISCO + SHUT ❑1' SHUTT TOFFF FOR LEAK,SYSDTEM FAILURE, GAPNHD SYS Ey D 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) ❑3.ANNUAL INTEGRITY TEST(0.1 GPH) C14. DAILY VISUAL CHECK CONVENTIONAL SUCTION SYSTEMS CONVENTIONAL SUCTION SYSTEMS(Check 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): ❑6. TRIENNIAL INTEGRITY TEST(0.1 GPH) SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): ❑7.SELF MONITORING [17. SELF MONITORING GRAVITY FLOW GRAVITY FLOW(Chick all that apply): ❑9.BIENNIAL INTEGRITY TEST(0.1 GPH) ❑8. DAILY VISUAL' ONITORING ❑9. BIENNIAL INTEGRITY TEST(0.1 GPH) SECONDARILY CONTAINED PIPING SECONDARILY CONTAINED PIPING PRESSURIZED PIPING(Check all that apply): PRESSURIZED PIPING(Check ail that apply): 10. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL 10. CONTINUOUS R 1SND�TURBINE)SUMP SENSOR WITH AUDIBLE AND VISUAL A ARMS AND(Check one) UTO PUMP SHUT OFF WHEN A LEAK OCCURS AUTO PUMP SHUT OFF WHEN A LEAK OCCURS b.'AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM b'D CONNECTION-TO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM DISCONNECTION ❑c NO ALTO PUMP SHUT OFF c. NO AUTO PUMP SHUT OFF I. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)WITH FLOW SHUT 11. AUTOMATIC LEAK DETECTOR OFF OR RESTRICTION ❑12. ANNUAL INTEGRITY TEST(O.I 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 WITHO1L AUTO PUMP SHUT OFF• ❑14• CANTIOEOUD VISUAL SUMP SENSOR O R I H 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 ❑I6.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 ❑2.CONTINUOUS DISPENSER PAN SENSOR+AUDIBLE AND VISUAL ALARMS ❑5.TRENCH LINER/MONITORING 469 3.CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR ❑6.NONE DISPENSER+AUDIBLE AND VISUAL ALARMS IX.OWNER/OPERATOR SIGNATURE 1 certify that e i io i he i 's true d accurate to the best of my knowledge. 470 TOR DATE SIGNATU F O 471 -71-TLE-OF OWNER/ PERA OR J/ 472 NAME OF OWNER/ TOR(Ari')M1 )(/ tK 473 Permit Appmvetl(For local use only) -473 Pennit Expiration Date(For local use only) 47 Permit Number(For 1oca1 Tuse UPCF(12/99 revised) 12 Formerly SWRCB Form B