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UNIFIED PROGRAM CONSOLIDATED FORM <br /> TANKS <br /> UNDERGROUND STORAGE TANKS -TANK PAGE 2 <br /> VL PIPING CONSTRUCTION(Check all that appy) <br /> UNDERGROUND PIPING ABOVEGROUND PIPING <br /> SYSTEM TYPE ❑ 1 PRESSURE ❑ 2. SUCTION ❑ 3. GRAVITY ❑ 1. PRESSURE C12. SUCTION ❑ 3. GRAVITY <br /> CONSTRUCTION/ ❑ 1. SINGLE WALL 1:13. LINED TRENCH Q 99. OTHER ❑ 1. SINGLE WALL ❑95. UNKNOWN <br /> MANUFACTURER ❑ 2 DOUBLE WALL ❑95. UNKNOWN ❑ 2. DOUBLE WALL C199 OTHER <br /> MANUFACTURER MANUFACTURER <br /> ❑ 1.BARE STEEL ❑ G. FRP COMPATIBLE W/100%METHANOL ❑ 1. BARE STEEL ❑ 8. FRP 6OMPATIBLE W/100%METHANOL <br /> MATERIALS AND ❑ 2_STAINLESS STEEL ❑ 7. GALVANIZED STEEL ❑ 2. STAINLESS STEEL <br /> CORROSION [17. GALVANIZED STEEL <br /> PROTECTION ❑ 3. PLASTIC COMPATIBLE WITH CONTENTS 1195 UNKNOWN ❑ 3. PLASTIC COMPATIBLE WITH CONTENTS ❑ 8. FLEXIBLE(HDPE) ❑99. OTHER <br /> ❑ 4. FIBERGLASS ❑ S. FLEXIBLE(HOPE) ❑99, OTHER. ❑ 4. FIBERGLASS ❑ 9. CATHODIC PROTECTION <br /> ❑ 5 STEEL W/COATING ❑ 9. CATHODIC PROTECTION ❑ 5. STEEL W/COATING 1:195, UNKNOWN <br /> VII.PIPING LEAK DETECTION(Check alf Nat apply) <br /> UNDERGROUND PIPING ABOVEGROUND PIPING <br /> SINGLE WALL PIPING SINGLE WALL PIPING <br /> PRESSURIZED PIPING(Check all that appy): 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 G 2 GPM TEST ❑ 3. ANNUAL INTEGRITY TEST(0.1 GPM) <br /> ❑ 3 ANNUAL INTEGRITY TEST(0 1 GPM) - <br /> ❑,4. GAILY VISUAL CHECK <br /> CONVENTIONAL SUCTION SYSTEMS: CONVENTIONAL SUCTION SYSTEMS(Check all that appal: <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) ❑ 8. 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 <br /> (Cr,eck one) 10.CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL ALARMS AND(check one) <br /> ❑ a AUTO PUMP SHUT OFF WHEN A LEAK OCCURS ❑ a. AUTO PUMP SHUT OFF WHEN A LEAK OCCURS <br /> ❑ 0 AUTO PUMPHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM <br /> DISCONNECTION C1 b AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM DISCONNECTION <br /> ❑ C. NO AUTO PUMP SHUT OFF ❑ c. NO AUTO PUMP SMUT OFF <br /> ❑ 11. AUTOMATIC LINE LEAK DETECTOR(3.0 GPM TEST)WITH FLOW SHUT OFF OR ❑ <br /> RESTRICTION 11. AUTOMATIC LEAK DETECTOR <br /> ❑ 12.ANNUAL INTEGRITY TEST(0 1 GPM) ❑ 12. ANNUAL INTEGRITY TEST(0.1 GPM) <br /> SUCTION/GRAVITY 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 appy) 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(3.0 GPM TEST) <br /> RESTRICTION <br /> ❑ 18. ANNUAL INTEGRITY TEST(0.1 GPM) ❑ 18. ANNUAL INTEGRITY TEST(0.1 GPM) <br /> ❑ 17. DAILY VISUAL CHECK ❑ IT DAILY VISUAL CHECK <br /> VII.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 ❑ S. NONE <br /> IX.OWNERIOPERATOR SIGNATURE <br /> I Certify that the intornaeon provided herein is true and accurate to the best of my knowledge. <br /> SIGNATURE OF OWNER/OPERATOR DATE <br /> NAME OF OWNER;'OPERATOR(phnt) TITLE OF OWNER/OPERATOR <br /> Permit Number(For local use only) Permit Approved(For focal use on Pernil Expiration Data(For Iotal use only) <br /> CUPAFORM(4199) Formerly SWRCB Form B <br />