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UNIFIED PROGRAM CONSOLIDATED FORM TANKS UNDERGROUND'STORAGE TANKS-TANK PAGE 2 ki x ' 0aCONSTRUCTION(Cheek aCthet apply)7 ace UNDERGROUND PIPING "= "- 3 �•i - ``'. 3 SYSTEM TYPE ABOVEGROUND PIPING 1. PRESSURE ❑2. SUCTION ❑ 3. GRAVITY 1.PRESSURE ❑ I. SINGLEWALL ❑ 3. LINEDTRENCH ❑2. SUCTION ❑ 3. GRAVITY CONSTRUCTION/ ❑99. OTHER ❑ 1.SINGLE WALL ❑95. UNKNOWN MANUFACTURER ❑y. DOUBLE WALL /�• ❑95. UNKNOWN MANUFACTURER IL 4- T _/ 2• DOUBLE WALL 1199. OTHER MANUFACTURER . ❑ 1.BARE STEEL ❑6. FRP COMPATIBLE W/100%METHANOL ❑ 1. BARE STEEL MATERIALS AND ❑ 2.STAINLESS STEEL ❑ 7. GALVANIZED STEEL ❑ 8.FRP COMPATIBLE W/100 h METHANOL CORROSION ❑2.STAINLESS STEEL ❑ 7.GALVANIZED STEEL PROTECTION ❑ 3. PLASTIC COMPATIBLE WITH CONTENTS ❑95. UNKNOWN ❑3. PLASTIC COMPATIBLE WITH CONTENTS ❑ a. FLEXIBLE(HDPE) ❑99.OTHER 4.'FIBERGLASS ❑ S. FLEXIBLE(HDPE) ❑99.OTHER . FIBERGLASS ❑ 9.CATHODIC PROTECTION• 5 STEEL W/COATING ❑8 CATHODIC PROTECTION ❑ 5 STEEL W/COATING 1195.x= 'VII,PIPINGCEAKgETECTTON(Ctxchalltha WN UNKNO x to �aa x H / UNDERGROUND PIPING -• SINGLE WALL PIPING ABOVEGROUND PIPING R SSURIZED PIPING(Check all that apply): . . SINGLE WALL PIPING 1. ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP SHUT OFF FOR PRESSURIZED PIPING(Check all that apply): LEAK,SYSTEM FAILURE,AND SYSTEM DISCONNECTION+AUDIBLE AND VISUAL ❑ 1. ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP SHUT OFF FOR LEAK, ALARMS SYSTEM FAILURE,AND SYSTEM DISCONNECTION AUDIBLE AND VISUAL ALARMS ❑ 2. MONTHLY 0.2 GPH TEST ❑ 2.MONTHLY 0.2 GPH TEST ❑ 3.ANNUAL INTEGRITY TEST(0.1 GPH) ❑ 3.ANNUAL INTEGRITY TEST(0.1 GPH) ❑ 4. DAILY VISUAL CHECK CONVENTIONAL SUCTION SYSTEMS: CONVENTIONAL SUCTION SYSTEMS(Check a/f that apply): ❑ 5. DAILY VISUAL MONITORING OF PUMPING SYSTEM+TRIENNIAL PIPING INTEGRITY ❑ 5.DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM TEST(0.1 GPH) ❑ SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): S.TRIENNIAL INTEGRITY TEST(0.1 GPH) ❑ 7. SELF MONITORING SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): ❑ GRAVITY FLOW: 7. SELF MONITORING � ' ❑ 9. BIENNIAL INTEGRITY TEST(0.1 GPH) GRAVITY FLOW(Check all that apply): ❑ 6. DAILY VISUAL MONITORING SECONDARILY CONTAINED PIPING C19. BIENNIAL INTEGRITY TEST(0.1 GPH) - PRESSURIZED PIPING(Check afl that apply): SECONDARILY CONTAINED PIPING 10CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL ALARMS AND PRESSURIZED PIPING(Check aU that apply): ane) AUTO PUMP SHUT OFF WHEN A LEAK OCCURS 10.CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL ALARMS AND(check one) Klima. ✓✓✓❑ b.AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM El a.AUTO PUMP SHUT OFF WHEN A LEAK OCCURS DISCONNECTION ❑b.AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM 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 OFF OR RESTRICTION ❑ 11.AUTOMATIC LEAK DETECTOR ❑ 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 am that apply) ❑ 14. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF+AUDIBLE AND EMERGENCY GENERATORS ONLY(Check ap that apply VISUAL ALARMS ❑ 14.CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF+AUDIBLE AND VISUAL El15.AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)WIT HQUi FLOW SHUT OFF OR ALARMS RESTRICTION ❑ 15.AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST) ❑ 16.ANNUAL INTEGRITY TEST(0.1 GPH) ❑ 17. DAILY VISUAL CHECK ❑ 16.ANNUAL INTEGRITY TEST(0.1 GPH) a - ❑ 17 DAILY VISUAL CHECK «` r 4PENNSERCONTAINMIETtl � mznr DISPENSER CONTAINMENT ❑ 1. FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE DATE IN LLED ❑2.CONTINUOUS DISPENSER PAN SENSOR+AUDIBLE AND VISUAL ALARMS ❑4. DAILY VISUAL CHECK 3. CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR DISPENSER+AUDIBLE A 11.5. TRENCH LINER/MONITORING NO VISUAL ALARMS ❑6. NONE I certify that the 'o p vided herein is true and ea=rate to the best of my krwvAedge.IX.OWNER/OPERATOR SIGNATURE SIGNATURE OF DATE NAME OF O RqT �� ?j TITLE O WOP B Lit ATOR Permit Number(Forktcal use oNy) Pamdt Approved(Forlaca/use only) - Pennk Expiration Data(Forloca/use only) ,UPAFORM(4/99) Formerly SWRCB Form B