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UNIFIED PROGRAM CONSOLIDATED FORM TANKS UNDERGROUND STORAGE TANKS - TANK PAGE 2 V1•PIPINGCONSTRUCTK)N(CheekaAfhatapplyj � .. - _: UNDERGROUND PIPING ABOVEGROUND PIPING SYSTEM TYPE ❑ 1 PRESSURE ❑ 2. SUCTION ❑ 3. GRAVITY ❑ 1. PRESSURE ❑ 2. SUCTION ❑ 3. GRAVITY CONSTRUCTION/0 1. SINGLE WALL ❑ 3. LINED TRENCH 1199. OTHER ❑ 1. SINGLE WALL ❑ 95. UNKNOWN MANUFACTURER 2. DOUBLE WALL ❑ 95. UNKNOWN ❑ 2. DOUBLE WALL ❑ 99. OTHER MANUFACTURER MANUFACTURER ❑ 1. BARE STEEL ❑ 8. FRP COMPATIBLE W! 100% METHANOL ❑ 1. BARE STEEL ❑ 8. FRP COMPATIBLE W/ 100% METHANOL MATERIALS AND ❑ 2, STAINLESS STEEL ❑ 7. GALVANIZED STEEL ❑ 2. STAINLESS STEEL ❑ 7. GALVANIZED STEEL CORROSION PROTECTION ❑ 3. PLASTIC COMPATIBLE WITH CONTENTS ❑ 95. UNKNOWN ❑ 3. PLASTIC COMPATIBLE WITH CONTENTS ❑ 8. FLEXIBLE (HDPE) - ❑ 99. OTHER 4. FIBERGLASS ❑ 8. FLEXIBLE (HDPE) ❑ 99. OTHER ❑ 4. FIBERGLASS ❑ 9. CATHODIC PROTECTION ❑ 5. STEEL W/ COATING ❑ 9. CATHODIC PROTECTION ❑ 5. STEEL W/ COATING ❑ 95. UNKNOWN VII. PIPING LEAK DETECTION (Cheek ad that apply) UNDERGROUND PIPING ABOVEGROUND PIPING SINGLE WALL PIPING PRESSURIZED PIPING (Check all that apply): SINGLE WALL PIPING PRESSURIZED PIPING (Check ak that apply): ❑ 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, LEAK, SYSTEM FAILURE, AND SYSTEM DISCONNECTION + AUDIBLE AND VISUAL SYSTEM FAILURE, AND SYSTEM DISCONNECTION ;AUDIBLE AND VISUAL ALARMS ALARMS ❑ 2. MONTHLY 0.2 GPM TEST ❑ 2. MONTHLY 0.2 GPM TEST ❑ 3. ANNUAL INTEGRITY TEST (0.1 GPM) ❑ 3, ANNUAL INTEGRITY TEST (0.1 GPM) ❑ 4. DAILY VISUAL CHECK CONVENTIONAL SUCTION SYSTEMS: CONVENTIONAL SUCTION SYSTEMS (Check all that apply): ❑ 5. DAILY VISUAL MONITORING OF PUMPING SYSTEM + TRIENNIAL PIPING INTEGRITY ❑ 5. DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM TEST (0.1 GPM) ❑ 8. TRIENNIAL INTEGRITY TEST (0.1 GPM) SAFE SUCTION SYSTEMS (NO VALVES IN BELOW GROUND PIPING): ❑ 7. SELF MONITORING SAFE SUCTION SYSTEMS (NO VALVES IN BELOW GROUND PIPING): ❑ 7. SELF MONITORING GRAVITY FLOW: ❑ 9. BIENNIAL INTEGRITY TEST (0.1 GPM) GRAVITY FLOW (Check all that apply): ❑ 8. DAILY VISUAL MONITORING ❑ 9. BIENNIAL INTEGRITY TEST (0.1 GPM) SECONDARILY CONTAINED PIPING PRESSURIZED PIPING (Check all that apply).: SECONDARILY CONTAINED PIPING PRESSURIZED PIPING (Check all that apply): 10. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL ALARMS AND (Check one) 10. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL 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 Elb. AUTO PUMP SHUT OFF FOR LEAKS, SYSTEM FAILURE AND DISCONNECTION ❑ C. NO AUTO PUMP SHUT OFF SYSTEM DISCONNECTION ❑ c. NO AUTO PUMP SMUT OFF ❑ 11. AUTOMATIC LINE LEAK DETECTOR (3.0 GPM TEST) WITH FLOW SHUT OFF OR ❑11. AUTOMATIC LEAK DETECTOR RESTRICTION ❑ 12. ANNUAL INTEGRITY TEST (0.1 GPM) ❑ 12. ANNUAL INTEGRITY TEST (0.1 GPM) SUCTION/GRAVITY SYSTEM: SUCTIOWGRAVITY SYSTEM: ❑ 13. CONTINUOUS SUMP SENSOR, AUDIBLE AND VISUAL ALARMS ❑ 13. CONTINUOUS SUMP SENSOR + AUDIBLE AND VISUAL ALARMS EMERGENCY GENERATORS ONLY (Check as that apply) EMERGENCY GENERATORS ONLY (Check all that apply) ❑ 14. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF +AUDIBLE AND ❑ 14. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF +AUDIBLE AND VISUAL VISUAL ALARMS ALARMS ❑ 15. AUTOMATIC LINE LEAK DETECTOR (3.0 GPM TEST) WITHOUT FLOW SHUT OFF OR ❑ 15. AUTOMATIC LINE LEAK DETECTOR (3.0 GPM TEST) RESTRICTION ❑ 18. ANNUAL INTEGRITY TEST (0.1 GPM) ❑ 18. ANNUAL INTEGRITY TEST (0.1 GPM) ❑ 17. DAILY VISUAL CHECK ❑ 17. DAILY VISUAL CHECK VOL DISPENSER CONTAINMENT DISPENSER CONTAINMENT X1. FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE ❑ 4. DAILY VISUAL CHECK DATE I ST LL ❑ 2. CONTINUOUS DISPENSER PAN SENSOR + AUDIBLE AND VISUAL ALARMS ❑ 5. TRENCH LINER / MONITORING ❑ 3. CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR DISPENSER + AUDIBLE AND VISUAL ALARMS ❑ 8. NONE IX. OWNERIOPERATOR SIGNATURE I certify that the information provided herein is true and accurate to the best of my knowledge. SIGNATURE OF OWNER/OPERATOR DATE NAME OF OWNER/OPERATOR (print) TITLE OF OWNER/OPERATOR i Permit Number (For local use only) Permit Approved (For local use only) Permit Expiration Date (For local use only) CUPAFORM (4/99) • • Formerly SWRCB Form B