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UNIFIED PROGRAM CONSOLIDATED FORM TANKS UNDERGROUND STORAGE TANKS - TANK PAGE 2 882-DIUI WGMG03:145 III VI. PIPING CONSTRUCTION Check all that apply) Page_2_of.2 UNDERGROUND PIPING ABOVEGROUND PIPING SYSTEM TYPE ❑ 1.PRESSURE ®2.SUCTION-FOS ®3.GRAVITY-FOR 458 ❑ 1.PRESSURE ®2.SUCTION-FOS N 3.GRAVITY-FOR 459 CONSTRUCTION/ ❑ I.SINGLE WALL ❑3.LINED TRENCH ❑99.OTHER 460 ® 1.SINGLE WALL ❑95.UNKNOWN 462 MANUFACTURER ®2.DOUBLE WALL ❑95.UNKNOWN ❑2.DOUBLE WALL ❑99.OTHER MANUFACTURER:.Primary:US Steel/Black Iron Secondary:Ameron Dualoy 3000/1.FRP 461 MANUFACTURER:Primary:Unknown/Black Iron 463 ®1.BARE STEEL-Pri ❑6.FRP COMPATIBLE W/1001%METHANOL ®I.BARE STEEL-Pri ❑6.FRP COMPATIBLE W/100%METHANOL ❑2.STAINLESS STEEL ❑7.GALVANIZED STEEL ❑95.UNKNOWN ❑2.STAINLESS STEEL ❑7.GALVANIZED STEEL ❑95.UNKNOWN ❑3.PLASTIC COMPATIBLE W/CONTENTS ❑99.OTHER ❑3.PLASTIC COMPATIBLE W/CONTENTS ❑99.OTHER ®4.FIBERGLASS-Sec ❑8.FLEXIBLE(HDPE) ❑4.FIBERGLASS ❑8.FLEXIBLE(HDPE) ❑5.STEEL W/COATING ❑9.CATHODIC PROTECTION 464 ❑5.STEEL W/COATING ❑9.CATHODIC PROTECTION 465 VII. PIPING LEAK DETECTION Check all that apply) A descrition of the monitoring program shall be submitted to the local agency.) UNDERGROUND PIPING ABOVEGROUND PIPING SINGLE WALL PIPING 466 SINGLE WALL PIPING 467 Note:Emergency Generator:Monthly inspections;AG piping excluded per H&S Code 25281.5(b)(3) PRESSURIZED PIPING(Check all that apply) PRESSURIZED PIPING(Check all that apply) ❑ 1.ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP SHUT ❑1. ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP OFF FOR LEAK,SYSTEM FAILURE,AND SYSTEM DISCONNECTION+ SHUT OFF FOR LEAK,SYSTEM FAILURE,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(0.1GPH) ❑3.ANNUAL INTEGRITY TEST(O.1GPH) ❑4. 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) ❑6. TRIENNIAL INTEGRITY TEST(0.1 GPH) SAFE SUCTION SYSTEMS(NO VALUES IN BELOW GROUND PIPING) SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING) ❑7.SELF MONITORING [:17. SELF MONITORING GRAVITY FLOW GRAVITY FLOW(Check all that apply) ❑9.BIENNIAL INTEGRITY TEST(0.1 GPH) ❑8. 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.CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL ALARMS AND(Check one) ALARMS AND(Check one) ❑a.AUTO PUMP SHUT OFF WHEN A LEAK OCCURS ❑a.AUTO PUMP SHUT OFF WHEN A LEAK OCCURS ❑b.AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM ❑b.AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM DISCONNECTION DISCONNECTION ❑c.NO AUTO PUMP SHUT OFF ❑c.NO AUTO PUMP SHUT OFF ❑11.AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)WITH FLOW SHUT ❑11.AUTOMATIC LEAK DETECTOR OFF OR RESTRICTION ❑12.ANNUAL INTEGRITY TEST(0.1 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 WITHOUT AUTO PUMP SHUT OFF+ ❑14.CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF+ AUDIBLE AND VISUAL ALARMS 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 ❑ 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 ❑2.CONTINUOUS DISPENSER PAN SENSOR+AUDIBLE AND VISUAL ALARMS ❑5.TRENCH LINER/MONITORING NA ❑3.CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR ®6.NONE 469 DISPENSER+AUDIBLE AND VISUAL ALARMS NERIOPERATOR SIGNATURE I certify that the information provided herein is true and accurate to thel3eseo y k w dg e. SIGNATURE OF OWNER/OPERATOR DATE 470 L 10/2/2003 NAME OF OWNER/OPERATOR(print) If 471 TITLE OF OWNER/OPERATOR 472 William G.Hoppes ly Group Leader,Water Guidance and Monitoring Group,Environmental Protection Department Permit Number(For local use only) 473 Permit Approved(For local use only) 474 Permit Expiration Date(For local use only) 475 UPCF(12/99 revised) Formerly SWRCB Form B