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UNIFIED PROGRAM CONSOLIDATED FORM T"M UNDERGROUND STORAGE TANKS - TANK PAGE 2 Page or VL PIPING CONSTRUCTION (Choc k of that tpPW UG. ERGROUMD PIPING ABOVEGROUND PIPING " SYSTEM TYPE RL4. PRESSURE ❑ 2. SUCTION ❑ 3. GRAVITY 458 ❑ 1. PRESSURE ❑ 2. SUCTION ❑ 3. GRAVITY 459 1. SINGLE WALL ❑ 3 LINED TRENCH ❑ 99. OTHER 460 ❑ 1. SINGLE WALL 1195. UNKNOWN 462 CONSTRUCTION/ MANUFACTURER [S'2_ DOGE WALL eQ 95 UNKNOWN 132. DOUBLE WALL 1399. OTHER /MAANUFACiURER / / /, 461 MANUFACTURER 463 ❑ 1. BARE STEEL C�j FRP COMPATIBLE W/ 100%h METHANOL ❑ 1. BARE STEEL ❑ 6. FRP COMPATIBLE W1100% METHANOL MATERIALS AND ❑ 2. STAINLESS STEEL ❑ 7. GALVANIZED STEEL ❑ 2. STAINLESS STEEL ❑ 7. GALVANIZED STEEL CORROSION PROTECTION ❑ 3. PLASTIC COMPATIBLE WITH CONTENTS ❑ 95. UNKNOWN 133. PLASTIC COMPATIBLE WITH CONTENTS ❑ 8. FLEXIBLE (HDPE) 1399. OTHER ❑ 4. FIBERGLASS ❑ 6. FLEXIBLE (HOPE) ❑ 99. OTHER ❑ 4. FIBERGLASS ❑ 9. CATHODIC PROTECTION ❑ S. STEEL WI COATING ❑ 9 CATHODIC PROTECTION 464 105. STEEL W/COATING ❑ 95. UNKNOWN 465 VII. PIPING LEAK DETECTION (Check ad that ^wW UNDERGROUND PIPING ABOVEGROUNO PIPING SINGLE WALLPIPING 466 SINGLE WALL PIPING 467 PRESSURIZED PIPING (Check aN that apply): PRESSURIZED PIPING (Check all that apply): ❑ 1. ELECTRONIC UNE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP SHUT OFF FOR ❑ 1. ELECTRONIC UNE ..EAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP SHUT OFF FOR LEAK LEAK SYSTEM FAILURE. AND SYSTEM DISCONNECTION + AUDIBLE AND VISUAL SYSTEM FAILURE AND SYSTEM DISCONNECTION • AUDIBLE AND VISUAL ALARMS ALARMS ❑ 2. MONTHLY 0.2 GPH TEST ❑ 2. MONTHLY 0.2 GPH TEST ❑ 3. ANNUAL INTEGRITY TEST (0.1 GPH) ❑ 3. ANIMAL INTEGRITY TEST (0.1 GPH) ❑ 4. DAILY VISUAL CFECCK CONVENTIONAL SUCTION SYSTEMS: CONVENTIONAL SUCTIO% SYSTEMS (Check all that apply): ❑ 5. DAILY VISUAL MONITORING OF PUMPING SYSTEM • TRIENNIAL PIPING INTEGRITY ❑ 5. DAILY VISUAL MOW70RING OF PIPING AND PUMPING SYSTEM TEST (0.1 GPH) ❑ 6. TRIENNIAL INTEL R?Y TEST (0.1 GPH) SAFE SUCTION SYSTEMS (NO VALVES IN BELOW GROUNO PIPING): SAFE SUCTION SYSTEMS NO VALVES IN BELOW GROUND PIPING): ❑ 7. SELF MONITORING ❑ 7. SELF MONITORING GRAVITY FLOW GRAVITY FLOW (Check at rat apply): ❑ 9. BIENNIAL INTEGRITY TEST (0.1 GPH) ❑ 8. DAILY VISUAL MONTORING ❑ 9. BIENNIAL INTEM-Y TEST (0.1 GPH) > SECONDARILY CONTAINED PIPING SECONDARILY CONTAINED PIPING PRESSURIZED PIPING (Check aN that appty): PRESSURIZED PIPING (Cdsck all that apply): 10. CONTINUOUS TURBINE SUMP SENSOR Wl� AUDIBLE AND VISUAL ALARMS AND 10. CONTINUOUS TUrSNE SUMP SENSOR WITH AUDIBLE AND VISUAL ALARMS AND (thea (Check one) one) ❑ AUTO PUMP SHUT OFF WHEN A LEAK OCCURS ❑ a. AUTO PUMP SHUT OFF WHEN A LEAK OCCURS AUTO PUMP SHUT OFF FOR LEAKS SYSTEM FAILURE AND SYSTEM DISCONNECTION ❑ b. AUTO PUMP SHUT OFF FOR LEAKS. SYSTEM FAILURE AND SYSTEM DISCONNEC T CN ❑ c. NO AUTO PUMP SHUT OFF ❑ c. NO AUTO P -NP SHUT OFF ❑ 11. AUTOMATIC LINE LEAK DETECTOR (3.0 GP- -EST) WITH FLOW SHUT OFF OR RESTRICTION ❑ 11. AUTOMATIC LEAr.:ETECTOR ❑ 12. ANNUAL INTEGRITY TEST (0.1 GPH) ❑ 12. ANNUAL INTEGR" "' TEST (0.1 GPH) SUCTIONiGRAVITY SYSTEM: ❑ 13 CONTINUOUS SUMP SENSOR - AUDIBLE ALD VISUAL ALARMS SUCTIONIGRAVITY SYSTEM: ❑ 13. CONTINUOUS SUWP SENSOR r AUDIBLE AND VISUAL ALARMS EMERGENCY GENERATORS ONLY (Check all that appy) ❑ 14. CONTINUOUS SUMP SENSOR WITHOUT AU -3 PUMP SHUT OFF - AUDIBLE AND AGENCY GENERATORS ONLY (Check all that apply) VISUAL ALARMS ❑ 14. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF ♦ AUDIBLE AND VISUAL ❑ 15. AUTOMATIC UNE LEAK DETECTOR (3.0 GPH -EST) WITHOUT FLOW SHUT OFF OR ALARMS RESTRICTION ❑ 15. AUTOMATIC UNE =:AK DETECTOR (3.0 GPH TEST) ❑ 16. ANNUAL INTEGRITY TEST (0.1 GPM) ❑ 16. ANNUAL INTEGRE'' TEST (0.1 GPH) ❑ 17 DAILY VISUAL CHECK ❑ 17. DAILY VISUAL CH' :K Vill. DISPENSER CONTAINMENT DISPENSER CONTAINMENT ❑ 1. FLOAT MEGH' % SM THAT SHUTS OFF SHEAR VALVE ❑ 4. DAILY VISUAL CHECK DATE INSTALLED 468 ❑ 2. CONTINUOUS :,SPENSER PAN SENSOR • AUDIBLE AND VISUAL ALARMS ❑ 5. TRENCH LINER; MONITORING . CONTINUOUS :-SPENSER PAN SENSOR WITH AUTO SHUT OFF FOR DISPENSER=_:IBLE AND VISUAL ALARMS ❑ 6. NONE dc9 IX. OWNER/OPERATOR SIGNATURE I certify that the Information praaded herein is true arc accurate to the best of my Knowledge. SIGNATURE OF 0\EPFRATOR I a DATE 470 N NAAAE OF OWNER/OPERAT n0 C 471 TITLE OF 0 ER/OPEzATOR 4-2 1 Permit Number (For local use only) 473 1 Fe -d Approved (For local use only) 474 1 Permit Expiration Date (For local use only! e'S UPCF (1)99) Formerly SWRCB Fc-" B