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UNIFIED PROGRAM CONSOLIDATED FORM TANKS UNDERGROUND STORAGE TANKS -TANK.PAGE 2 682-DIUI,VGMG03145 a VL PIPING CONSPRUcrm Check all that.pom 11x8. 2_of - J_ 0 UNDERGROUND PIPING ABOVEGROUND PIPING 1 SYSTEM TYPE ❑I.PRESSURE ®2.SUCTION-FOS ®3.GRAVITY-FOR 458 ❑1.PRESSURE ®2.SUCTION-Fos ®3.GRAVITY-FOR 459 CONSTRUCTION/ ❑1.SINGLE WAIL ❑3.LINEDTRENCH ❑99.OTHER 460 ®1 SINGIA WALL ❑95 UNKNOWN 462 MANOFACTUREK®2.DOUBLE WALL ❑95.UNKNOWN ❑2.DOUBLE WALL ❑99.OTHER MANUFACFURER:Primary,US S1ee1 I Black Iron Secmdary Amnm Dualm 3fX)&L FRY 461 MANUFACTURER:Pnm y:Unknos n i Black Iron 463 ® I.BARE STFY..1;Ni ❑6 FRP COMPATIBLE W/100'.METHANOL ®1 BARE-STFEL-Pe ❑6 FRP COMPATIBLE W/101P1.6fETf IANOL ❑2.STAINLESS S"t'EF.E. ❑7 GALVANIZED STEEL ❑95 LNK\OR'N ❑2.STAINLESS STE:EI. ❑7.GALVANIZED STEEL ❑95.UNKNOWN ❑3.PLASTIC COMPATIBLE W!CONTENTS ❑99 OTHER ❑3 PLAS 1C.COMPATIBLE Wi CONTENTS ❑w)onu;R ®4.FIBERGLASS-Sec Q 8 FLE3tml-E(IIDPE) ❑4.FIBERGLASS ❑S FlxxmLE(HDPE.) Q S.BTEEL W/COATNG ❑9.CATHODIC PKOTECFION 464 ❑5.STEEL W:COATING ❑9.CATHODIC PROTECTION 465 VII. PIPING LEAD DETECTION Cbak all 1h.1 a v)(A descririm 05'11,,.mmiarim plV.m shall be submitted to the Im.l a cn ) UNDERGROUND PIPING ABOVEGROUND PIPING SINGLE WALL PIPING 46-6 SINGLE WALL.PIPING 467 Nose.Emergency Gwerator:Mmthly inspectims,.AG Piping excluded per IMS Code 25281 5(b)(3) PRESSURIZED PIPING(Check all that apply) PRESSI IRIZED PIPING(Chick a'I that apply) ❑ I.ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TESL WI1h AULO PUMP SHUT ❑L ELECTRONIC LINE LEAK DETECTOR 3 o GPH-/ESI-wl1.11 AUTO PUMP OFF FOR LEAK,SYSTEM FAILURE,AND SYSTEM DISCONNECTION+ SHUT OFF FOR LEAK,SYSTEM FAILURE,AND S YS_[EM DISCONNFUNON AUDIBLE AND VISUAL ALARMS. At,DIBLH AND VISUAL.ALARMS. ❑2.MONTHLY 0.2 GPH TEST ❑2. RIONI'l1LY 0.2 GP}ITEST ❑3.ANNUAL INTEGRITY TF.S-r(I),IGPH) ❑A ANNUAL.INTEGRITY TEST(OAGPH) ❑4. DAILY VISUAL CHECK CONVENTIONAL SUCTION SYS7"EMS CON'VF.NTIVNAL SUCTION SYS'T'EMS rCh«k ail tha;apply) ❑5.DAILY VISUAL MONITORING OF PUMPING SYSTEM+TRIENNIAL PIPING INTEGRITY TEST(0.1 GPI 1) ❑5 DAILY VISUAL VIONr['ORiNG Cif PIPING AND PUMPING SYSTEM ❑6. 7l([[{NNIAL INIEGI(I l'Y 11{ST(O.1 GPH) SAFE SUCTION SYSTEMS(NO VALUES IN BELOW GROUND PIPING) SAF)':SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING) ❑7.SELF MONITORING ❑7. SELF MONITORING GRAVITY FLOW GRAVITY FLOW(Check all th t apply) 119.BIENNIAL INTEGRITY MST(0.1 GPH) [IS. DAILY VISUAL MONrrORING ❑9. BIENNIAL INrEGRrrY TEST(0.1(,Pit) SECONDARILY CONTAINED PIPING SECONDARILY CONTAINED PIPING PRESSURIZED PIPING(Check e11 that apply) PRESSURIZED PIPING(Check all that apply) 10.CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL 10 CONTINUOUS TURBINE SUMP SENSOR tYJRI AUDIBLE AND VISUAL ALARMS AND(Chea);me) ALARMS AND(Chak me) ❑R.AUTO PUMP SHUT OFF WHEN A LEAK OCCURS ❑x AUTO PUMP Sim,mz WHEN A LEAK OCCURS ❑b.AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM ❑b.AUTO PUMP SHUTOFF FOR LEAKS.SYSTEM FAILURE AND SYS FLM DISCONNECTION DISCONNECTION ❑c.NO AUTO PUMPSHUT OFF ❑c.NO AUTO PUMP SHUT OFF ❑11.AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TESD WITH FLOW SH}JT ❑11 AUTOMATIC LEAK DETECTOR OFF OR RESTRICTION ❑12.ANNUAL IN'IT:GRITY'1'EST(U.1 GPH) ❑12.ANNUAL INTEGRITY TEST(0 1 GPH) SUCIIUN/GRAVITY SYSTEM SUCTIOWGRAVITY SYSTEM ❑I3.CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS ❑13 CONTINUOUS SUMP SENSOR AUDIBLE AND VISUAL ALARMS EMERGENCY GENERATORS ONLYCheck all that apply)pply) F.11F-RGENCI'GENERA-TORS ONLY(0-k.11 that apply) R 14.CONTINUOUS SUMP SENSOR WETHOIJT AUTO PUMP SHUT OFF* ❑14 CONTINUOUS SUMP SENSOR Y/1Tt[pUT AUTO PUMP SHUT OFF+ AUDIBLE AND VISUAL ALARMS AUDIBLE AND VISUAL ALARMS ❑15.AUTOMATIC LINE LEAK DETECTOR(3.0 GPH 11-ST)WITHOUT FLOW ❑15 AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST) SHUT OFT OR RESTRICIION ❑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 ❑S.TRENCH LINER/,MONITORING ORING ❑NA 3.CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR DISPENSER+AUDIBLE AND VISUAL ALARMS ®6.NONE 469 _ IX, MVNER/0PERATOR SIGN A'ITRE I wtify that the intotmatim wided herein is,,nae and accurate to th yk w ee. SIGNATURE,OF OWNER/OPERA TUR DATE 470 10/2/2003 NAME:OF OWNER/OPERATOR(print) JIL471 TITLE OF OWNER'OPERATOR 47? William G.Hoppes Group Leader,Water Guidance and hltmitoring Gr p,Emirmmcntal Prowaim Depw-ent Permit Ntmtber(For Imal uu Mv) 473 Permit Approved(Por Ictal use oMy) 4?4 Pcrmit L•xpi;a!ion Date(For Itx;al ux mlyi 4'S LJPCF(12/99 revisedl Formerly SWRCB Form B (