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r Alk UNIFUD PROGRAM CONSOLIDATED FORM TANKS UNDERGROUND STORAGE TAN -TANK PAGE 2 VI.PIPING CONSTRUCTION Clmckall that Page_of_ UNDERGROUND PIPING ABOVEGROUND PIPING SYSTEM TYPE ffif.PRESSURE ❑2 SUCTION ❑3.GRAVITY 458 ❑1_PRESSURE ❑2 SUCTION ❑3.GRAVITY 459 CONSTRUCTION ❑1.SINGLE WALL ❑3.LINED TRENCH ❑99.OTHER 460 ❑1.SINGLE WALL ❑95.UNKNOWN 462 j MANUFACTURER 2.DOUBLE WALL ❑95.UNKNOWN ❑2 RUBLE WALL ❑99.OTHER MANUFACTURER 461 MANUFACTURER 463 ❑1.BARE STEEL ❑6.FRP COMPATIBLE w/100°.6 METHANOL ❑1.BARE STEEL ❑6.FRP COMPATIBLE W/100%METHAN0L ❑2.STAINLESS STEEL ❑7.GALVANIZED STEEL, ❑Unimmn ❑2 STAINLESS STEEL ❑7_GALVANIZED STEEL. ❑3. LASTIC COMPATIBLE W/CONTENTS ❑99. Other ❑3_PLASTIC COMPATIBLE W/CONTENTS ❑8.FLEXIBLE(HDPE) ❑99. OTHER FIBERGLASS ❑8.FLEXIBLE(RDPE) ❑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 y)(A deactiptiott of the monitoring progratn shall be submittedto the local agency.) UNDERGROUND PIPING ABOVEGROUND PIPING SINGLE WALL PIPING 466 SINGLE WALL PIPING 467 PRESSURIZED PIPING(Check all that apply): PRESSURIZED PIPING(Check au that apply): ❑1.ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP SHAT ❑1. ELECTRONIC L iNE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP OFF FOR LEAK,SYSTEM FAILURE,AND SYSTEM DISCONNECTION+ SHUT OFF FOR LEAK,SYSTEM FAILURE,AND SYSTEM DISCONNECTION+ 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(QI GPH) SAFE SUCTION SYSTEMS(NO VALUES IN BELOW GROUNDPIPING): ❑6. TRIENNIA.INTEGRITY TEST(0.1 GPH) ❑7.SELF MONITORING SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): GRAVITY FLOW [17. SELF MONITORING ❑9.BIENNIAL INTEGRITY TEST(0.1 GPH) GRAVITY FLOW(Check all that apply} ❑8. DAILY VISUAL MONITORING [19- BIENNIAL INTEGRITY TEST(0.1 GPH) SECONDAPJLY 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 AL,WS 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 c. NO AUTO PUMP SHUT OFF ❑e NO AUTO PUMP SHUT OFF 1. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)WT1 FLOW SHUT OFF OR RESTRICTION ❑11. AUTOMATIC LEAK DETECTOR ❑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 a 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 ❑17.DAILY VISUAL CHECK VIII.DISPENSER CONTAINMENT DISPENSER CONTAINMENT ❑1.FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE ❑4.DALLY VISUAL CHECK DATE INSTALLED468 ❑2_DO PN.ONTINUOTINUEDOU3 DIDISPENSER PAN SPAN SFED.I]30R+��AUDIBLELAND VI®FF AFOARI.ARMS® 6.NTRENCH LINER.!MONITORING 469 IX.OWNERIOPERATOR SIGNATURE I certify that the information provided herain is true and accurate to the beat of my knowledge. S[G rak& ®A DA ®z azo NAME OF OWNER/OPRATOR 471 TITLE OF OWN WOPERATOR 472 s7t-V£-✓ F. G 41r7rw27- PLXrewa weFRINc m ANff ery Fl2, Pemut Number(For local use only) 473 Permit Approved(For local use only) 474 Permit Expiration Date(For local use only) 475 UPCF(12/99 revised) 12 Formerly SWRCB Form B