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UNIFIED PROGRAM CONSOLIDATED FORM e <br /> TANKS <br /> UNDERGROUND STORAGE TANKS -TANK PAGE 2 <br /> Pace of <br /> VI.PIPING CONSTRUCTION(Check ad that apply) <br /> UNDERGROUND PIPING ABOVEGROUND PIPING <br /> SYSTEM TYPE ❑ 1 PRESSURE ❑ 2. SUCTION t-❑ 3. GRAVITY 111. PRESSURE C32. SUCTION C33. GRAVITY <br /> CONSTRUCTION/ C11. SINGLE WALL 113. LINED TRENCH Q 99.-OTHER ❑ 1. SINGLE WALL ❑95. UNKNOWN <br /> MANUFACTURER ❑ 2 DOUBLE WALL ❑95. UNKNOWN ❑ 2. DOUBLE WALL ❑99. OTHER <br /> MANUFACTURER MANUFACTURER <br /> ❑ 1.BARE STEEL ❑ 8. FRP COMPATIBLE W/100%METHANOL ❑ 1. BARE STEEL ❑ 8. FRP COMPATIBLE WI 100%METHANOL <br /> MATERIALS AND ❑ 2. STAINLESS STEEL ❑ 7. GALVANIZED STEEL ❑ 2. STAINLESS STEEL ❑ 7. GALVANIZED STEEL <br /> CORROSION <br /> PROTECTION ❑ 3. PLASTIC COMPATIBLE WITH CONTENTS ❑95. UNKNOWN ❑ 3. PLASTIC COMPATIBLE WITH CONTENTS ❑ 8. FLEXIBLE(HOPE) ❑99. OTHER <br /> ❑ 4. FIBERGLASS ❑ 8. FLEXIBLE(MOPE) ❑99. OTHER ❑ 4. FIBERGLASS ❑ 9. CATHODIC PROTECTION <br /> ❑ 5. STEEL Al COATING ❑ 9. CATHODIC PROTECTION ❑ 5. STEEL W/COATING ❑95. UNKNOWN <br /> VII.PIPING LEAK DETECTION(Check art that appy) <br /> UNDERGROUND PIPING ABOVEGROUNO PIPING <br /> SINGLE WALL PIPING SINGLE WALL PIPING <br /> PRESSURIZED PIPING(Check all that apply): PRESSURIZED PIPING(Check all that apply): <br /> ❑ 1. ELECTRONIC LINE LEAK DETECTOR 3.0 GPM TEST WITH AUTO PUMP SHUT OFF FOR ❑ 1. ELECTRONIC LINE LEAK DETECTOR 3.0 GPM TEST WITH AUTO PUMP SHUT OFF FOR LEAK, <br /> LEAK,SYSTEM FAILURE,AND SYSTEM DISCONNECTION+AUDIBLE AND VISUAL SYSTEM FAILURE,AND SYSTEM DISCONNECTION+AUDIBLE AND VISUAL ALARMS <br /> ALARMS ❑ 2. MONTHLY 0.2 GPM TEST <br /> ❑ 2. MONTHLY 0.2 GPM TEST ❑ 3. ANNUAL INTEGRITY TEST(0.1 GPM) <br /> ❑ 3. ANNUAL INTEGRITY TEST(0.1 GPM) ❑.4. DAILY VISUAL CHECK <br /> CONVENTIONAL SUCTION SYSTEMS. CONVENTIONAL SUCTION SYSTEMS(Check all that apply): <br /> ❑ 5. DAILY VISUAL MONITORING OF PUMPING SYSTEM-TRIENNIAL PIPING INTEGRITY ❑ 5. DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM <br /> TEST(0 1 GPM) ❑ B. TRIENNIAL INTEGRITY TEST(0.1 GPM) <br /> SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): <br /> ❑ 7. SELF MONITORING ❑ 7. SELF MONITORING <br /> GRAVITY FLOW- GRAVITY FLOW(Check all that apply): <br /> ❑ 9. BIENNIAL INTEGRITY TEST(0.1 GPM) ❑ 8. DAILY VISUAL MONITORING <br /> ❑ 9. BIENNIAL INTEGRITY TEST(0.1 GPM) <br /> SECONDARILY CONTAINED PIPING SECONDARILY CONTAINED PIPING <br /> PRESSURIZED PIPING(Check all that apply): PRESSURIZED PIPING(Check all that apply): <br /> 10 CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL ALARMS AND 10.CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL ALARMS AND(check one <br /> (Check one) ) <br /> ❑ a AUTO PUMP SHUT OFF WHEN A LEAK OCCURS ❑ a. AUTO PUMP SHUT OFF WHEN A LEAK OCCURS <br /> ❑ b AUTO PUMP HUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM <br /> DISCONNECTION C11) AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM DISCONNECTION <br /> ❑ c. NO AUTO PUMP SHUT OFF ❑ c. NO AUTO PUMP SHUT OFF <br /> ❑ 11. AUTOMATIC LINE LEAK DETECTOR(3.0 GPM TEST)WITH FLOW SHUT OFF OR ❑ 11. AUTOMATIC LEAK DETECTOR <br /> RESTRICTION <br /> ❑ 12. ANNUAL INTEGRITY TEST(o.1 GPM) ❑ 12. ANNUAL INTEGRITY TEST(0.1 GPM) <br /> SUCTIONIGRAVITY SYSTEM: SUCTION/GRAVITY SYSTEM: <br /> ❑ 13. CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS ❑ 13. CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS <br /> EMERGENCY GENERATORS ONLY(Check all that apply) EMERGENCY GENERATORS ONLY(Check all that apply) <br /> ❑ 14. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF+AUDIBLE AND ❑ 14. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF+AUDIBLE AND VISUAL <br /> VISUAL ALARMS ALARMS <br /> ❑ 15. AUTOMATIC LINE LEAK DETECTOR(3.0 GPM TEST)WITHOUT FLOW SHUT OFF OR ❑ 15. AUTOMATIC LINE LEAK DETECTOR(3.o GPM TEST) <br /> RESTRICTION <br /> ❑ 16. ANNUAL INTEGRITY TEST(0.1 GPM) ❑ 16. ANNUAL INTEGRITY TEST(0.1 GPM) <br /> ❑ 17. DAILY VISUAL CHECK ❑ 17. DAILY VISUAL CHECK <br /> VIII.DISPENSER CONTAINMENT <br /> DISPENSER CONTAINMENT ❑ 1. FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE ❑ 4. DAILY VISUAL CHECK <br /> DATE INSTALLED ❑ 2. CONTINUOUS DISPENSER PAN SENSOR+AUDIBLE AND VISUAL ALARMS ❑ 5. TRENCH LINER/MONITORING <br /> ❑ 3. CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR DISPENSER+AUDIBLE AND VISUAL ALARMS ❑6. NONE <br /> IX.OWNERIOPERATOR SIGNATURE <br /> I certify that the information provided herein is We and accurate to the best of my knowledge. <br /> SIGNATURE OF OWNER/OPERATOR DATE <br /> NAME OF OWNEWOPERATOR(print) TITLE OF OWNER/OPERATOR <br /> Permit Number(For local use only) Panni/Approved(For local use o Permit Expiration Date(For local use only) <br /> t <br /> CUPAFORM(4/99) • . Formerly SWRCB Form B I <br />