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S,-,P-14-2004 16:00, SRC 9259730584 P.03 <br /> lb <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> TANKS <br /> UNDERGROUND STORAGE TANKS-TANK PAGE 2 <br /> VLPIPING CONSTRUCTION Check au That i Palle_of_ <br /> UNDERGROUND PIPING <br /> I ABOVEGROUND PIPING <br /> SYSTEM TYPE C3 I.PRESSURE z.SUCTION 0 3.GRAVITY 438 p 1,.PRESSURE U2�, SUCTION 0 3.GRAVITY 459 <br /> commucrioN 111 SINGLE WALL L3 3,LINED TRENCH M 99,O'niER 960 1,SINGLE WALL U 95.UNKNOWN -462 <br /> MANUFACTURER SK DOUBLE WALL [j 95,UNKNOWN C3 2.DOUBLE WALL E]99.OTHER <br /> MANUFACTURER bJL'!:S7t-ZW jf1=6ass 461 MANUFACTURER s7rF/- 463 <br /> (3 1.BARE STEEL IJ 6,FRP COMPATIBLE w1160% METHANOL BARE STEEL 0 6.FRP COMPATIBLE-wii00%mETaANoL <br /> 0 2.STAINLESS STEEL [3 7.GALVANIZED STEEL C3 Unknown 0 2. STAINLESS STEEL (3 7.GALVANIZED STEEL <br /> 13 3.PLASTIC COMPATIBLE W/CONTENTS (:j 99, Other 03. PLASTIC COMPATIBLE W/CONTENTS [18.FLEXIBLE(HI)PE) 099. OTHER <br /> C3 4.FIBERGLASS ef FLEXIBLE(HDPE) 114. FIBERGLASS 13%CATHODIC PROTECTION <br /> 05-SMELWICOATING E39,CATHODIC PRO-MCT;ON 464 0 S. STUL WICOATING 0 95,UNKNOWN 465 <br /> VII.PIPING LEAK DETECTION Check all'bat apply)(A lftaLtLm <br /> ,, <br /> -=-it� am" a <br /> I to aubmillud to m local agertcv.) <br /> UNDERGROUND PIPING <br /> ABOVEGROUND PIPING <br /> SINGLE WALL PIPING 4" SINGLE WALL PIPING 467 <br /> PMSSUR1210 PIPING(ChV*311 LINAL apply): PRESSURIZED PIPING(atock,all that apply): . <br /> 0 1.ELECTRONIC LINE LEAK DETECT-OR 3.0 GPH TEST M=AUTO PUMP SHUT 0 1. ELECTRONIC LINE LEAK DETECTOR 10 GPH TEST 3MIU3 AUTO PUMP <br /> OFF FOR LEAK,SYSTEM FAILURE,AND SYSTEM DISCONNECTION+ SHUT OFF FOR LEAK,SYSTEM FAILURE.AND SYSTEM DISCONNECTION+ <br /> AUDIBLE AND VISUAL ALARMS. AUDIBLE AND VISUAL ALARMS. <br /> 132.MONTHLY 0.2 GPH TEST F-1 2. MONTHLY 0,2 GPH TEST <br /> E3 3.ANNUAL INTEGRITY TEST(0.l GPH) 0 3.ANNUAL INTEGRITY TEST(0,[GPM) <br /> 0 4. DAILY VISUAL CHECK <br /> CONVENTIONAL SUCTION SYSTEMS CONVENTIONAL SUCTION SYSTEMS(Check all jhm ppply) <br /> ❑5.DAILY VISUAL MONITORING OF PUMPING SYSTEM+TRIENNIAL PIPING <br /> )NTEGRITY TEST(0.1 GPM) D S. DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM <br /> SAFE SUCTION SYSTEMS(NO VALUES IN®PLOW GROUNDPIPING): 0 6. TRIENNIAL INTEGRITY TEST(o.I opm) <br /> C3 7.SELF MONITORING SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): <br /> GRAV77Y FLOW 0 7. SELF MONITORING <br /> 9.BIENNIAL INTEGRITY TEST(0.1 OPH) GRAVITY FLOW(Cbmk all am apply): <br /> [IS. DAILY VISUAL MONITORING <br /> El 9. BIENNIAL INTEGRITY TEST(0.1 GPM) <br /> SECONDARILY CONTAINED PIPING SECONDARILY CONTAINED PIPING <br /> PRESSURIZED PIPING(Check all rhal Applyy PRESSURIZED PIPING(Chock W)that apply) <br /> 10- CONTINUOUS TURBINE SUMP SENSOR I=AUDIBLE AND VISUAL 10, CONTINUOUS TURBINE SUMP SENSOR WFM AUDIBLE AND VISUAL <br /> ALARMS AND(Check cuz) ALARMS AND(Check one) <br /> 13;1. AUTO PUMP SHUT OFF WHEN A LEAK OCCURS [J a AUTO PUMP SHUT OFF WHEN A LEAK OCCURS <br /> LJ b. AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM 13 b AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM <br /> DISCONNECTION DISCONNECTION <br /> 0c. NO AUTO PUMP SHUT OFF [30 NO AUTO PUMP SHUT OFF <br /> 0 11. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)AM FLOW SHUT <br /> OFF OR RESTRICTION 11. AUTOMATIC LEAK DETECTOR <br /> Ej 12. ANNUAL INTEGRITY TEST(0.1 GPM) 0 12. ANNUAL INTEGRITY TEST(0.1 OPH) <br /> SUCTION/GRAVITY SYSTEM SUCTION/GRAVITY SYSTEM <br /> 0 13. CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS 0 13, CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS <br /> M',, EMERGENCY GENERATQRS ONLY(Ch..kjl Lh..Wy) EMERGENCY GENERATORS ONLY(Chock all jhaL apply) <br /> 14_CONTINUOUS SUMP SENSOR W11=AUTO PUMP SHUT OFF 14. CONTINUOUS SUMP SENSOR WITHOUTAUTO PUMP SHUT OFF <br /> AUDIBLE AND VISUAL,ALARMS AUDIBLE AND VISUAL ALARMS <br /> 13 15. <br /> AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)WI TOUT FLOW <br /> SHUT OFF OR RESTRICTION ❑IS. AUTOMATIC LINE LEAK DETECTOR(3-0 GPH TEST) <br /> [116-ANNUAL INTEGRITY TEST(0.1 GPH) ❑16.ANNUAL INTEGRITY TEST(0.1 GPH) <br /> [3 17. DAILY VISUAL CHECK ❑17. DAILY VISUAL CHECK <br /> VIII,DISPENSER CONTAINMENT <br /> DISPENSER CONTAINMENT' 0 1.FLOAT MECHANrSMTHAT SHUTS OFF SHEAR VALVE Q 4,DAILY VISUAL CHECK <br /> DATE INSTALLS 4M D 2.CONTINUOUS;DISPENSER PAN SENSOR+AUDIBLE AND VISUAL ALARMS 115.TRENCH LINER/MONITORING <br /> A/ r! <br /> (13,CONTINUOUS,DISPRNSER PAN SENSOR W"AUTO SHUT OFF FOR <br /> DISPENSER+AUDIBLE AND VISUAL ALARMS 6,NONE ago <br /> IX.OWNERIOPERATOR SIGNATURE <br /> IcutKythat the insumdonprovided hemqn 4 Due and doctraLa 6 do bmi otww knowicrip. <br /> SIG ATIUJ IF OWNEPWJ!0PE1 Top 9. DATE 470 <br /> --7 <br /> NAME <br /> fOWNER/OPRATOR Vpt)"' 471 TITLE OF OWNER/OP E&ATQR, 472 <br /> AM <br /> WIVACEPW <br /> Pcmdt Wu-mberTft-r local use only) 471 <br /> Permit Approved(For local un only) 4 Fmi,t Expirdfi:Ome(Fir low no 473 <br /> UIPCF(12/99 revised) 12 Formerly SWRCB Form B <br />