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UNIFIED PROGRAM CONSOLIDATED FORM
<br /> TAJNK
<br /> UNDERGROUND STORAGE TANKS - TANK PAGE 2
<br /> VL.PIPING CONSTRUCTION,(Check ali that apply Page-
<br /> UNDERGROUND PIPING �( ABOVEGROUND PIPING
<br /> Tti'PL JURE ❑2 SUCTION �.1:. IRAN!" 458 I,1 PRE, URL C1%. SUCTION ❑3.GRAVITY 459
<br /> CO STp'C?IGiJ ❑1 ;IkG_F'WA;.L (]3.LINED TRENCH ❑`^Q )TF,�P: Ito ]1 S[NUuE'A,,LL ❑95 UNKNOWN 462
<br /> MA 'UFACTURER 2 CGUBLE'NALL ©95.UNKNOWN ❑2.DOUBLE vVA_.. ❑99,OTHER
<br /> N1AhJUFr:CTURER ,81 MANUFA.CTURc�
<br /> � 463
<br /> ❑ BARE STEc_ ❑6 -RP,OMPATIBLE w710e% MFH.ANOo I ❑1 BARE STEEL ❑6.FRP COMPATIBLE wrto0%METHANOL
<br /> ❑" STAI1"LEo _ ❑7 3ALVANIZED STEEL ❑ IUdUV`dN I❑2. STAINLESS STE F.J. ❑7 GALVANIZED STEEL
<br /> Q ❑ 9. OTHER I ❑3. PLASTIC COMPPTIBLF Vv CONTENTS ❑8.FLEX;3'_F(HDPE) ❑55. OTHER
<br /> Fib_ �Ln.. ❑N F.LX!BLE;HDPE) L❑4. FIBERGLASS ❑9.CATHODIC PROTECTION !
<br /> ❑ .STFpL N i:;A.TiNG ❑S.'3ATHODIC PROTECTION 464 ❑5. STEEL VWCOA-ING ❑95 'JtvKNOWN 465 E
<br /> VII.PIPING I K DETECTION;Crlacx all that apply)(A desr riptron-of the munitcr.ng program snau.be subrttitted to the local agency.)
<br /> r-a -� --- ABOVEGROUND PIPING
<br /> UNDERGROUND PIPING
<br /> SINGLE WALL PIPING _-_- 465 SINGLE WALL PIPING 467
<br /> .1 rRESSURIZED PIPING t,eck all that apply;
<br /> k PRL._..URIZcr:PIP!' ; P
<br /> Q t LTEt t ' -FH'FST W,TH AJTU 'JMFI -FF FOR ❑''. ELE7 RO IC LAVE,FAK DE'ECTOR 3.0 GPH TEST WITH AUTO PUMP SHUT OFF FOR
<br /> r +tifEr P.E.tiP CTrMCSGONNEGTION AUui�Lt �D r!cU•AL LEAK S� cM AI lRE.ANDSYSTEMDISCOVrJ;:G710N+AUDIBLE AND VISUAL
<br /> v Ftr ALARM
<br /> ❑2 IA NT TEST ❑2 lAONTHL 2: { FEST
<br /> I ❑to �tvP.GAL >,�rGPI'+TE"! ;0 ❑3- ANNUAL (%TE rRJY TEST 0.1GPH)
<br /> J ❑4 GAILY VISLA�CIHECK
<br /> i
<br /> Cr' `rF.`, IOtiM ' r y gi CONVENTIONAL SUC C-N,,15 i EMS(Check all that apply)
<br /> Q 5 p, r r_ .Jr ,r n t._ ^F�!!("tPIhJ SYSTEM-rRi,.tJ,IAL P•F Nc''r1TL ,RITY ❑5. DAILY V•ISU&_ C.F ORING OF PIPING AND PUMPING SYSTEM
<br /> SnF >LC i ION o" P i (NC JA!UES IN pELCrW GROUNDPIP!NG) U,3: IRIENNA'..W � .LEST(0.1 GPH)
<br /> "AI'E SILCI DD..,y t`J w:.VAt AS IN BELOW GROUND PIPING)07
<br /> !
<br /> I GQ7.
<br /> SELr rvtn VIf J 2 PI;
<br /> TW.V'Tl 't,
<br /> I; ❑9. A!EiJtJlh'.I1r r?!` ,E_��1..i hrlf) .sRAV!i7 FLOtv ``eel A na•applyl .
<br /> 1 09 31 NP li;' �FTTE 7p).1GWH) t
<br /> E SFCONOARIL f CONTAINED PIPING I SECONDARILY CONTAINED PIPING
<br /> I
<br /> PRESSURIZED P f a, cp: SSI nIZCr v K aIi that a c
<br /> 10 i+ � TrTH �,b'..-Ft�.0 r.-_ I R4?rdANC SUVPSc 0R,,' _T'r _-.1SLEAN::vISUALALARMS AND
<br /> I » ifh
<br /> t r $F I G As.OCCURS -
<br /> HUT CFF WHEN A A
<br /> - F...
<br /> SYS rA L. i L - =.s': ❑^ -, r ? C;
<br /> =FO S urJ ILLRE AND SYSTEM
<br />�� r, • 'r TSC riN
<br /> SI^L'T OFF
<br />¢t
<br /> []1 L n AA L N.. EAY _ _ k t'_J GPh 1=ST)VYI N rLGUV`,>nUTGFF j 1 UI ,t T __-A,�. TFCTOR
<br /> 'O
<br /> a. Cl12. ;;r ,LAI NTL R.TY TEST(0.1 GPH)
<br /> ❑12 at L 'J 1 UPr T 7 TEST(5 I GPH)
<br /> S r 5 F:bS
<br /> I �]13 SUMP SENSOR,AJ -r --A1,C-VISUAL X.-ARV`. ❑ 3. (GN IfvLUL Lf 1P SENSOR-AUDIBLE AND VISUAL ALARMS
<br /> EMERGENCY GENERATORS ONLY(cne n t"GI auu ri
<br /> EMERGENCY GENERATORS ONLY;Check all that apply)
<br /> ❑14 XNT1tv0G11,,SUMP ScnSOR Vdr`1 JT AU TO PUMP SHUT C-FF-41,013F, LND Q 14 OONTNUOUo SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF-AUDIBLE AND
<br /> VIst;AL r;LA.RNIFS VISUAL ALARMS
<br />!' C]15. AUTON"NT!C LINE LEAK DETECTOR(30 GPh TEST;LOI HOLT F':iV SHL T 0 i OR
<br /> f C3 15. AUTOMATIC LINE LEA+(DETECTOR(3.0 GPH TEST)
<br /> G- ricSTRIC;IOP;
<br /> ❑15 ANNUA.'_'NTcGRiTY TE`T;ll''3PH1 i ❑16 ANNUAL.JJFGR•IY TEST(0 1 GPH)
<br /> ❑1?. DAILv JSiJAL ❑17 DA LY VISUAL;HECK
<br /> Vlll.DISPENSER CONTAINMENT
<br /> DISPENSER ❑ , P-047 MECHANISM THAI ',14UT L '1W AIR VALVE ❑4 DAILY VISUAL(;HECK
<br /> CONTAINMENT
<br /> DATE INSTALLED 468 ❑2 CONTINUOUS DiSPENS_fi •aN SENSOR-AUDIBLE AND VISUAL ALARMS ❑5 TRENCH LINER r MONITORING
<br /> 01, GGNTiNUOUS DISPENS �PAN SENIOR WITH AUTO SHUT OFF FOR DISPENSER- [�6.NONE
<br /> 469
<br /> AL;DIBLE AND VISUAL
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<br /> r.
<br /> IX OWNER/OPEFtATOR SIGNATURE
<br /> f. sv�� Io accurate to ns c:e _>r � g_
<br /> I
<br /> - 470
<br /> - � r`
<br /> (.
<br /> 1 r L E D F R A T 472
<br /> Jac'; Dlrectcr of Er gi,7ee ing
<br /> c ..o_":,F. ,.xa;,�s=_only; -rmaExprraiionDate,worrccatuseonly)
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