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UNIFIED PROGAM CONSOLIDATED FORM b R TANKS UNDERGROUND STORAGE TANKS -TANK PAGE 2 VI.PIPING CONSTRUCTION Check all that I Page_of_ UNDERGROUND PIPING ABOVEGROUND PIPING SYSTEM TYPE 1.PRESSURE [12.SUCTION ❑3.GRAVITY 458 ❑1.PRESSURE ❑2. SUCTION ❑3.GRAVITY 459 CONSTRUCTION ❑MINGLE WALL ❑3.LINED TRENCH ❑99.OTHER 460 ❑1.SINGLE WALL 95.UNKNOWN 467. MANUFACTURERX2.DOUBLE WALL 95.UNKNOWN ❑2.DOUBLE WALL ❑99.OTHER MANUFACTURER ( 461 MANUFACTURER 463 ❑1.BARE STEEL ❑6.FRP COMPATIBLE w/100% METHANOL ❑1.BARE STEEL ❑6.FRP COMPATIBLE W/IOOY.METHANOL ❑2.STAINLESS STEEL [17.GALVANIZED STEEL $UnlatOwn ❑2. STAINLESS STEEL ❑7.GALVANIZED STEEL [13.PLASTIC COMPATIBLE W/CONTENTS ❑99. Other ❑3.PLASTIC COMPATIBLE W/CONTENTS ❑8.FLEXIBLE(HDPE) ❑99.OTHER ❑4.FIBERGLASS ❑S.FLEXIBLE(HDPE) ❑4.FIBERGLASS ❑9.CATHODIC PROTECTION ❑5.STEEL W/COATING ❑9.CATHODIC PROTECTION 464 ❑5. STEEL W/COATING 95.UNKNOWN 465 VII.PIPING LEAK DETECTION(Check all that )(A description of the monitorin program shall be submitted to the local .) UNDERGROUND PIPING ABOVEGROUND PIPING SINGLE WALL PIPING GPH 466 SINGLE WALL PIPING 467 rPRESSURIZEDD PIPING(Check all drat apply): PRESSURIZED PIPING(Check all that apply):NIC LINE LEAK T Y=AUTO PUMP R LEAK SYSTEM FAILURE AND SYST M DISCONNE("3ION LEA +ECTOR 3.0 GPH TEST WITH AUTO P SHUT SHUT❑1 pF FOR LEAK SYSTEMOLURE A AUTO PUMP R 3.0 GPH SYST SCONNECI ION+E AND VISUAL ALARMS. AUDIBLE AND VISUAL ALARMS. LY 0.2 GPH TEST ❑2. MONTHLY 0.2 GPH TEST L INTEGRITY TEST(O.IGPH) ❑3.ANNUAL INTEGRITY TEST(O.1GPH) ❑4. DAILY VISUAL CHECK NAL SUCTION SYSTEMS CONVENTIONAL SUCTION SYSTEMS(Check All that apply) . VISUAL MONITORING OF PUMPING SYSTEM+TRIENNIAL PIPING ❑5. DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM INTEGRITY TEST(0.1 GPH) SAFE SUCTION SYSTEMS(NO VALUES IN BELOW GROUNDPIPING): ❑6.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): ❑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 A VISUAL 10. ISS OUNSDTU SIN SUMP SENSOR WITH AUDIBLE AND VISUAL ALARMS AND(Check one) ❑a AUTO PUMP SHUT OFF WHEN A LEAK OCCURS ❑a AUTO PUMP SHUT OFF WHEN A LEAK OCCURS f b. AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM [Ib AUTO PUMP SH OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM 1 DISCONNECTION CTION ❑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 [I t2. ANNUAL INTEGRITY TEST(0.1 GPH) ❑12. ANNUAL INTEGRITY TEST(O.l GPH) SUCTION/GRAVITY SYSTEM SUCTION/GRAVITY SYSTEM ❑13. CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS ❑ CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS 13. CONTI EMERGENCY GENERATORS ONLY(Check all that apply) EMERGENCY GENERATORS ONLY(Check all that apply) [3 14. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF a 1--]14.CION NUOAUSSDSUM SE VISUAL SENSOR HOUT AUTO PUMP SHUT OFF 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 1 ❑17.DAILY VISUAL CHECK VIII.DISPENSER CONTAINMENT DISPENSER CONTAINMENT ❑1.FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE ❑4.DAILY VISUAL CHECK DATE INSTALLED 468 [12.CONTINUOUS DISPENSER PAN SENSOR+AUDIBLE AND VISUAL ALARMS ❑5.TRENCH LINER/MONITORING �tiu� d P�C/ "3.CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR ❑6.NONE 461 DISPENSER+AUDIBLE AND VISUAL ALARMS IX.OWNER/OPERATOR SIGNATURE I cenify that the information provided herein is true and accurate to the best of my knowledge. 4.ro SIGNATURE OF OWNER//OPERAti T DATE c l� - 2 V NAME OF OWNER/OPRATOR(print) 47I TITLE OF R/OPERATOR 7 _ 472 ` ( E6 473 Permit Approved(For lora)use only) 474 Permit Expiration Date(For Ioral use only) 475 Permit Number(For local use only) UPCF(12/99 revised) 12 Formerly SWRCB Form B