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i is I UNIFIED PROGRAM (UP)FORM UNDERGROUND STORAGE TANKS -TANK PAGE 2 VI.PIPING CONSTRUCTION(Check all that apply) Page of UNDERGROUND PIPING ABOVEGROUND PIPING SYSTEM TYPE 0 1.PRESSURE [12.SUCTION ❑3.GRAVITY 458 ❑1.PRESSURE ❑2. SUCTION ❑3.GRAVITY 459 CONSTRUCTION P1.SINGLE WALL ❑3.LINED TRENCH ❑99.OTHER 46o ❑1.SINGLE WALL ❑95.UNKNOWN 462 MANUFACTURER 012.DOUBLE WALL ❑95.UNKNOWN ❑2.DOUBLE WALL ❑99.OTHER MANUFACTURER 461 MANUFACTURER 463 MATERIALS AND ❑1 BARE STEEL ❑6.FRP COMPATIBLE w/100% CORROSION METHANOL 01.BARE STEEL ❑6.FRP COMPATIBLE W/100%METHANOL PROTECTION 1712.STAINLESS STEEL ❑7.GALVANIZED STEEL ❑2.STAINLESS STEEL ❑7.GALVANIZED STEEL 10 95.UNKNOWN ❑3.PLASTIC COMPATIBLE W/CONTENTS ❑8.FLEXIBLE(HDPE) ❑3.PLASTIC COMPATIBLE ❑g FLEXIBLE(HDPE)❑95.UNKNOWN W/CONTENTS ❑4.FIBERGLASS ❑9.CATHODIC PROTECTION ❑4. FIBERGLASS ❑9.CATHODIC PROTECTION ❑5.STEEL W/COATING ❑99.OTHER 464 ❑5. STEEL W/COATING ❑99. OTHER 465 Vll.PIPING LEAK DETECTION(Check all that apply)(A description of the monitoring program shall be submitted to the local agency.) UNDERGROUND PIPING 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 1711. ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP SHUT OFF FOR LEAK,SYSTEM FAILURE,AND SYSTEM SHUT OFF FOR LEAK,SYSTEM FAILURE,AND SYSTEM DISCONNECTION+AUDIBLE AND VISUAL ALARMS. DISCONNECTION+AUDIBLE AND VISUAL ALARMS. ❑2.MONTHLY 0.2 GPH TEST ❑2. MONTHLY 0.2 GPH TEST ❑3.ANNUAL INTEGRITY TEST(0.1GPH) ❑3.ANNUAL INTEGRITY TEST(0.1GPH) E]4. DAILY VISUAL CHECK CONVENTIONAL SUCTION SYSTEMS(Check all that apply) CONVENTIONAL SUCTION SYSTEMS(Check all that apply) 1715.DAILY VISUAL MONITORING OF PUMPING SYSTEM+TRIENNIAL PIPING 115. DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM INTEGRITY TEST(0.1 GPH) ❑6. TRIENNIAL INTEGRITY TEST(0.1 GPH) SAFE SUCTION SYSTEMS(NO VALUES IN BELOW GROUNDPIPING): SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): [17.SELF MONITORING [17. SELF MONITORING GRAVITY FLOW GRAVITY FLOW(Check all that apply): 119.BIENNIAL INTEGRITY TEST(0.1 GPH) ❑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 ❑b AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM SYSTEM DISCONNECTION DISCONNECTION NO AUTO PUMP SHUT OFF ❑c NO AUTO PUMP SHUT OFF 11. AUTOMATIC LEAK DETECTOR(3.0 GPH TEST) WITHFLOW SHUT OFF ❑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 17115. AUTOMATIC LEAK DETECTOR(3.0 GPH)WITHOUT FLOW SHUT OFF ❑15. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST) ❑16.ANNUAL INTEGRITY TEST(0.1 GPH) ❑17. DAILY VISUAL CHECK ❑16.ANNUAL INTEGRITY TEST(0.1 GPH) ❑17. DAILY VISUAL CHECK Vill.DISPENSER CONTAINMENT DISPENSER CONTAINMENT ❑1.FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE 4.DAILY VISUAL CHECK DATE INSTALLED 468 112.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 that the information provided herein is true and accurate to the best of my knowledge. :z;;;l NER/OP TOR DATE 470 NAME OF OWNE OPRATOR(print)_ TITLE OF OWNER/OPERATOR f f 472 +eve% t Jr in red a i � OFFICIAL USE ONLY Permit Number 473 1 Permit Approved 474 Permit Expiration Date 475 UP FORM(1/2000 Version) 3 UPF_LAC4:07_USTB THE CUPAs OF LOS ANGELES COUNTY