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UNIFIED PROGRAM CONSOLIDATED FO TANKS UNDERGROUND STORAGE TANKS - TANK PAGE 2 (Check all that apply) Page_of_ UNDERGROUND PIPING ABOVEGROUND PIPING SYSTEM TYPE ❑1.PRESSURE ®2.SUCTION ❑3.GRAVITY 458 1.PRESSURE 02. SUCTION ❑3.GRAVITY 459 CONSTRUCTION ❑1.SINGLE WALL 3.LINED TRENCH ❑99.OTHER 460 ®1.SINGLE WALL 95.UNKNOWN 462 MANUFACTURER ®2.DOUBLE WALL 95.UNKNOWN 2.DOUBLE WALL 99.OTHER MANUFACTURER ENVIROFLEX 461 MANUFACTURER STEEL 463 1.BARE STEEL o 6.FRP COMPATIBLE W/100% METHANOL ®1.BARE STEEL 6.FRP COMPATIBLE W/l00%METHANOL ❑2.STAINLESS STEEL ❑7.GALVANIZED STEEL Ej Unknown [3 2. STAINLESS STEEL 7.GALVANIZED STEEL 0 3.PLASTIC COMPATIBLE W/CONTENTS 0 99. Other 3. PLASTIC COMPATIBLE W/CONTENTS 8.FLEXIBLE(HDPE) []99. OTHER 114.FIBERGLASS 08.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 DE I ECI ION(Check all that apply)(A description of the monitoring program shall be submitted to the local agency.) UNDERUROUND-PIP119G- ABOVEGROUND PIPING SINGLE WALL PIPING 466 SINGLE WALL PIPING 467 PRESSURIZED PIPING(Check all that apply): PRESSURIZED PIPING(Check all that apply): 1.ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP SHUT ❑1. ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP OFF FOR LEAK,SYSTEM FAILURE,AND SYSTEM DISCONNECTION+ SHUT OFF FOR LEAK,SYSTEM FAILURE,AND SYSTEPIDISCONNECTION+ AUDIBLE AND VISUAL ALARMS. 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 all that apply) 5.DAILY 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) 117.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 AND VISUAL 10. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL ALARMS AND(Check one) ALARMS AND(Check one) a. AUTO PUMP SHUT OFF WHEN A LEAK OCCURS ❑a AUTO PUMP SHUT OFF WHEN A LEAK OCCURS b. AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM b AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM DISCONNECTION DISCONNECTION 0c. 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 0 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 all that apply) EMERGENCY GENERATORS ONLY(Check all that apply) ®14. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF• ®14. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF AUDIBLE AND VISUAL ALARMS AUDIBLE AND VISUAL ALARMS 15. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)WITHOUT FLOW SHUT OFF OR RESTRICTION 15. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST) 16.ANNUAL INTEGRITY TEST(0.1 GPM 16.ANNUAL INTEGRITY TEST(0.1 GPH) 17. DAILY VISUAL CHECK 17. DAILY VISUAL CHECK VIII.DISPENSER CONTAINMENT DISPENSER CONTAINMENT 1.FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE 4.DAILY VISUAL CHECK DATE INSTALLED 468 ❑2.CONTINUOUS DISPENSER PAN SENSOR+AUDIBLE AND VISUAL ALARMS 5.TRENCH LINER/MONITORING ❑3.CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR []6.NONE 469 DISPENSER+AUDIBLE AND VISUAL ALARMS IX.OWNER/OPERATOR SIGNATURE I certify at the information provided herein is true and accurate to the best of my knowledge. DATE 470 May 29,2001 nn Masood H.Choudhury Environmental Consultant Permit Number or local use only) Permit Approved(For ca use only) Permit Expiration Date or local use only) UPCF(12/99 revised) lqw 12 Formerly SWRCB Form B