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UNIFIED PROGRAM CONSOLIDATED FORM TANKS UNDERGROUND STORAGE TANKS - TANK PAGE 2 I - P_ VI.PIPING CONSTRUCTION c Ichoc an mat appy) UNDERGROUND PIPING j ABOVEGROUND PRANG SYSTEM TYPE ,"�. PRESSURE ❑2. SUCTION ❑ 3. GRAVITY 456 i❑ 1. PRESSURE ❑ 2. SUCTION ❑ 3 GRAVITY 459 coNSTRucnow•i❑ 1. SINGLE WALL ❑3. LINED TRENCH ❑99. OTHER 460 J'❑ 1. SINGLE WALL ❑95 UNKNOWN 462 MANUFACTURER]o§2 DOUBLE WALL ❑95. UNKNOWN i❑ 2. DOUBLE WALL ❑99 OTHER MANUFACTURER A-0- S Y-%t T tA 461 MANUFACTURER 463 ❑ 1.BARE STEEL 6. FRP COMPATIBLE VA 100%METIiANOI ❑ 1. BARE STEEL ❑ 6 FRP COMPATIBLE W/100%ME7TiANOL MATERLALS AND j❑ 2. STAINLESS STEEL ❑ 7. GALVANIZED STEEL ❑2 STAINLESS STEEL ❑ 7. GALVANIZED STEEL CORROSION PROTECTION 1❑ 3. PLASTIC COMPATIBLE WITH CONTENTS ❑95. UNKNOWN ❑ 3. PLASTIC COMPATIBLE WITH CONTENTS ❑ 6. FLEXIBLE(HDPE) ❑99 OTHER j❑ 4. FIBERGLASS ❑6. FLEXIBLE(HDPE) ❑99. OTHER ❑4. FIBERGLASS ❑ 9. CATHODIC PROTECTION I❑ 5. STEEL W/COATING ❑9. CATHODIC PROTECTION 464 ❑ 5. STEEL WI7 COATING ❑95 UNKNOWN 465 VN.PIPING LEAK DETECTION(Check as awapply)(A des w6m o!the mor*wm program shag 4e su0mi0ed to em bur agency.) UNDERGROUND PIPING I ABOVEGROUND PIPING SINGLE WALL PIPING 466 SINGLE WALL PIPING ,7 PRESSURIZED PIPING(Check all VW apply): PRESSURIZED PIPING(Check a///1at appy): ❑ 1 ELECTRONIC LINE LEAK DETECTOR 3.0 GPM TEST WITH AUTO PUMP SHUT OFF FOR ❑ 1. ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP SHUT OFF FOR LEAK LEAK SYSTEM FAILURE.AND SYSTEM DISCONNECTION•AUDIBLE AND VISUAL SYSTEM FAILURE.AND SYSTEM DISCONNECTION+AUDIBLE AND VISUAL ALARMS 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 I CONVENTIONAL SUCTION SYSTEMS: CONVENTIONAL SUCTION SYSTEMS(Check M mat appy): ❑ 5 DAILY VISUAL MONITORING OF PUMPING SYSTEM•TRIENNIAL PIPING INTEGRITY ❑ 5. DAILY VISUAL MONrTORING OF PIPING AND PUMPING SYSTEM TEST(0.1 GPH) ❑ 6. TRIENNIAL INTEGRITY TEST(0.1 GPM) - SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING) SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING). ❑ 7 SELF MONITORING I❑ 7. SELF MONITORING GRAVITY FLOW. GRAVITY FLOW(Check all ON appy): ❑ 9 BIENNIAL INTEGRITY TEST.(0.1 GPH) - ❑ S. DAILY VISUAL MONITORING ❑ 9. BIENNWLINTEGRITYTEST(O.1GPM) SECONDARILY CONTAINED PIPING SECONDARILY CONTAINED PIPING PRESSURIZED PIPING(Check a#mat appy): PRESSURIZED PIPING(Chea all mat appy): 10. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL ALARMS AND I 10. CONTINUOUS TURBINE SUMP SENSOR WPI' AUDIBLE AND VISUAL ALARMS AND(v,aksc one) (Cneccone) ❑ a. AUTO PUMP SHUT OFF VHEN A LEAK OCCURS ❑ a AUTO PUMP SHUT OFF WHEN A LEAK OCCURS ®0. AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM I ❑b AUTO PUMP SHUT OFF FOR LEAKS.SYSTEM FAILURE AND SYSTEM DISCONNECTION DISCONNECTION �5 ❑ c NO AUTO PUMP SHUT OFF ❑ c NO AUTO PUMP SHUT OFF ICy 11 AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)WITH FLOW SHUT OFF OR ❑ 11. AUTOMATIC LEAK DETECTOR RESTRICTION ❑ 12 ANNUAL INTEGRrrY TEST(0.1 GPM) ❑ 12. ANNUAL INTEGRrrY TEST(0.1 GPH) SUCTIOWGRAVTTY SYSTEM. SUCTIONIGRAVITY SYSTEM. i I ❑ 13 CONTINUOUS SUMP SENSOR•AUDIBLE AND VISUAL ALARMS ❑ 13 CONTINUOUS SUMP SENSOR•AUDIBLE AND VISUAL ALARMS EMERGENCY GENERATORS ONLY(Chea au mat appy) EMERGENCY GENERATORS ONLY(Chea aP that appy) ❑ 14 CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF-AUDIBLE AND ❑ 14. CONTINUOUS SUMP SENSOR WIT HO, AUTO PUMP SHUT OFF•AUDIBLE AND VISUAL VISUAL ALARMS ALARMS ❑ 15 AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)WITHOUT FLOW SHUT OFF OR ❑ 15. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST) RESTRICTION i ❑ 16. ANNUAL INTEGRITY TEST(0.1 GPM) I❑ 16. ANNUAL INTEGRITY TEST(0.1 GPH) ❑ 17. DAILY VISUAL CHECK ❑ 17. DAILY VISUAL CHECK V5L DISPENSER CONTABMAENT DISPENSER CONTAINMENT ❑ 1. FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE ❑ 4 DAILY VISUAL CHECK �I q DATE INST 466 ❑ 7. CONTINUOUS DISPENSER PAN SENSOR•AUDIBLE AND VISUAL ALARMS C35. TRENCH LINER I MONITORING I�3. CONTINUOUS DISPENSER PAN SENSOR'M AUTO SHUT OFF FOR DISPENSER•AUDIBLE AND VISUAL ALARMS ❑ 6. NONE 469 DL OWNERIOPERATOR SIGNATURE I ow*VW the r6ormabon pmvded here is M4and amme b Vn Dai of my wrowwve. SIGNATURE OF OWNE BATOR DATE ( / I S O 470 NAME OF OWMERIOPERATOR(pn 471 TITLE OF OWNER/OPERATOR J 472 SLJ'V_14 LA/rL�i12 / to i A- -Or'L_ Penna Number(For ro=ar use only) 473 Permit Approved(For bW use only) 474 PWMA EXPretlon Date(For bW un only) 475 UPCF(1/99 revised) 7 Fomierty SWRCB Form 8