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UNIFIED PROGRAM CONSOLIDATED FOFM <br /> TANK <br /> UNDERGROUND STO TANKS - TANK PAGE 2 <br /> VL,PIPING CONSTRIIl(Check ail that.apply) : Page-of <br /> UNDERGROUND PIPING ABOVEGROUND PIPING <br /> SYSTEM TYPE ® PRESSURE [:12.SUCTION ❑3 GRAVITY 458 ❑1.PRESSURE ❑2. SUCTION ❑3.GRAVITY 459 <br /> CONSTRUCTION,, ❑!.SINGLE WALL ❑3.LINED TRENCH ❑99.OTHER 460 ❑1.SINGLE WALL ❑95.UNKNOWN 462 <br /> MANUFACTURER ®2.DOUBLE WALL ❑95.UNKNOWN ❑2.DOUBLE WALL ❑99.OTHER <br /> MANUFACTURER <br /> 461 MANUFACTURER 463 <br /> ❑1.BARE STEEL ❑6.FRP COMPATIBLE w1100% METHANOL ❑1.BARE STEEL ❑6.FRP COMPATIBLE wnoo%METHANOL <br /> ❑2.STAINLESS STEEL ❑7.GALVANIZED STEEL ❑UKNOWN ❑2. STAINLESS STEEL ❑7.GALVANIZED STEEL <br /> ❑3.PLASTIC COMPATIBLE W/CONTENTS ❑99 OTHER ❑3. PLASTIC COMPATIBLE W/CONTENTS ❑8.FLEXIBLE(HDPE) ❑99. OTHER <br /> ®4.FIBERGLASS ❑8.FLEXIBLE(HDPE) ❑4. FIBERGLASS ❑9.CATHODIC PROTECTION <br /> ❑5.STEEL W/COATING [:19.CATHODIC PROTECTION 464 ❑5. STEEL W/COATING ❑95.UNKNOWN 465 <br /> "- VII.PIPING LEAK DETEGTION`(Check.all that apply)(A description of.the monitoring program shall be sutimitted.to the local agency.) .. <br /> UNDERGROUND PIPING ABOVEGROUND PIPING <br /> SINGLE WALL PIPING 466 SINGLE WALL PIPING 467 <br /> PRESSURIZED PIPING(Check all that apply): PRESSURIZED PIPING(Check all that apply): <br /> ❑1 ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP SHUT OFF FOR ❑1. ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP SHUT OFF FOR <br /> LEAK,SY�TEM FAILURE.AND SYSTEM DISCONNECTION+AUDIBLE AND VISUAL LEAK,SYSTEM FAILURE.AND SYSTEM DISCONNECTION+AUDIBLE AND VISUAL <br /> ALARMS. ALARMS. <br /> ❑2. MONTHLY 0.2 GPH TEST ❑2. MONTHLY 0.2 GPH TEST <br /> ❑3. ANNUAL INTEGRITY TEST(0,1GPH) ❑3. ANNUAL INTEGRITY TEST(0.1GPH) <br /> ❑4. DAILY VISUAL CHECK <br /> CONVENTIONAC'SUCTION SYSTEMS CONVENTIONAL SUCTION SYSTEMS(Check all that apply) <br /> ❑5. DAILY VISUAL MONITORING OF PUMPING SYSTEM-TRIENNIAL PIPING INTEGRITY ❑5. DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM <br /> TEST(0.1 GPH) <br /> SAFE SUCTION SYSTEMS(NO VALUES IN BELOW GROUNDPIPING): E36. TRIENNIAL INTEGRITY TEST(0.1 GPH) <br /> ❑7. SELF MONITORING SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): <br /> GRAVITY FLOW ❑7. SELF MONITORING <br /> ❑9. BIENNIAL INTEGRITY TEST(0.1 GPH) GRAVITY FLOW(Check all that apply): <br /> ❑8. DAILY VISUAL MONITORING <br /> ❑9. BIENNIAL INTEGRITY TEST(0.1 GPH) <br /> SECONDARILY CONTAINED PIPING SECONDARILY CONTAINED PIPING s <br /> PRESSURIZED PIPING(Check all that apply) PRESSURIZED PIPING(Check all that apply). <br /> 10. CONTINUOUS?URBINE SUMP SENSOR WITH AUDIBLE AND VISUAL ALARMS AND 10. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL ALARMS AND <br /> i ;Chem one, (Check one) <br /> i ❑a ,1-C°UMP SHUT OFr"',NHEN A LEAK OCCURS ❑a AUTO PUMP SHUT OFF WHEN A LEAK OCCURS <br /> Ob ,AUTO PUMP SHUT OFF FOR LEAKS.SYSTEM FAILURE AND SYSTEM ❑b AUTO PUMP SHUT OFF FOR LEAKS.SYSTEM FAILURE AND SYSTEM <br /> DISCONNECTION DISCONNECTION <br /> ❑c. NO AUTO PUMP SHUT OFF ❑c NO AUTO PUMP SHUT OFF <br /> [111. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)WITH FLOW SHUTOFF OR ❑11. AUTOMATIC LEAK DETECTOR <br /> RESTRICTION <br /> ❑12. ANNUAL INTEGRITY TEST(0.1 GPH) ❑12. ANNUAL INTEGRITY TEST(0.1 GPH) <br /> SUCTION/GRAVITY SYSTEM SUCTION/GRAVITY SYSTEM <br /> El 11 CONTINUOUS SUMP SENSOR+AUDIBLE ANDVISUAL ALARMS C3 13. CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS <br /> EMERGENCY GENERATORS ONLY(Check all that apply) EMERGENCY GENERATORS ONLY(Check all that apply) <br /> ❑14. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF+AUDIBLE AND [114. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF AUDIBLE AND <br /> VISUAL ALARMS VISUAL ALARMS <br /> ❑15. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)WITHOUT FLOW SHUT OFF OR ❑15. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST) <br /> RESTRICTION <br /> ❑16. ANNUAL INTEGRITY TEST(0.1 GPH) ❑16. ANNUAL INTEGRITY TEST(0.1 GPH) <br /> ❑17. DAILY VISUAL CHECK ❑17. DAILY VISUAL CHECK <br /> „ <br /> Vill.DISPENSER.CONTgINMENT <br /> DISPENSER ❑i. FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE ❑4.DAILY VISUAL CHECK <br /> CONTAINMENT <br /> DATE INSTALLED 468 ❑2. CONTINUOUS DISPENSER PAN SENSOR+AUDIBLE AND VISUAL ALARMS ❑5.TRENCH LINER t MONITORING <br /> ®3. CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR DISPENSER+ ❑6.NONE 469 <br /> AUDIBLE AND VISUAL ALARMS <br /> IX.OWNERIOPERATOR SIGNATURE <br /> „I certify':❑at the ntorn,at n pro ided herein. s i ue and accurate to the best o.ary knowiedge. <br /> SIGNS IA- RE .F LATE C NER PEPN.'' ;' 470 <br /> a � � A.. � <br /> NAME Yip r�PRATO TITLE OF OW ', <br /> NER PERATOR 472 <br /> Jack Rhoad Director of Engineering j <br /> /Ocal,ase only, - Pero,:Aoproceo i For local use only) Permit Expiration Date,For iocst use only) <br /> 475 <br />