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UNIFIED PROGRAM CONSOLIDATED FORM TANKS UNDERGROUND STORAGE TANKS — TANK PAGE 2 Pan, 70 I VI.PIPING CONSTRUCTION(Chock as that apply) UNDERGROUND PIPING ABOVEGROUND PIPING SYSTEM TYPE 1 PRESSURE ❑ 2 SUCTION ❑ a GRAVITY ❑ 1 PRESSURE ❑ 2. SUCTION ❑ 0 GRAVITY CONSTRUCTION/ ❑ 1 SINGLE WALL ❑--I-7 LINED TRENCH ❑99 OTHER ❑ 1 SINGLE WALL ❑95 UNKNOWN MANUFACTURER � tb DOUBLE WALL r 5 11d1�NC1W1O. /� C32- DOUBLE WALL C3 99 OTHER MANUFACTURER EN 4i n G Itis `I��- MANUFACTURER ❑ 1 BARE STEEL ❑ B FRP COMPATIBLE W/100%METHANOL ❑ 1. BARE STEEL ❑ 6. FRP COMPATIBLE W/100%METHANOL MATERIALS AND ❑ 2. STAINLESS STEEL ❑ 7. GALVANIZED STEEL ❑ 2. STAINLESS STEEL ❑ 7. GALVANIZED STEEL CORROSION PROTECTION ❑ 0 PLASTIC COMPATIBLE WITH NTENTS [:3 95 UNKNOWN ❑ 0 PLASTIC COMPATIBLE WITH CONTENTS ❑ 6 FLEXIBLE(HOPE) 99 OTHER 4 FIBERGLASS 6 FLEXIBLE(HDPE) ❑99 OTHER ❑ 4 FIBERGLASS ❑ 9 CATHODIC PROTECTION ❑ 5 STEEL W/COATING ❑ 9. CATHODIC PROTECTION 10 5 STEEL W/COATING ❑95 UNKNOWN VII.PIPING LEAK DETECTION(Check all that appty) UNDERGROUND PIPING ABOVEGROUND PIPING SINGLE WALL PIPING SINGLE WALL PIPING PRESSURIZED PIPING(Chack all that apPIY). PRESSURIZED PIPING(Check•11 that agoty)- ❑ 1. ELECTRONIC UNE LEAK DETECTOR 7.0 GPM TEST WITH AUTO PUMP SHUT OFF FOR ❑ 1. ELECTRONIC LINE LEAK DETECTOR 0 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 GPH TEST ❑ 2. MONTHLY G 2 GPM TEST ❑ 3 ANNUAL INTEGRITY TEST(0.1 GPM) ❑ 7 ANNUAL INTEGRITY TEST(0 1 GPM) ❑.4. DAILY VISUAL CHECK CONVENTIONAL SUCTION SYSTEMS(Chack all that apPW CONVENTIONAL SUCTION SYSTEMS. ❑ 5 DAILY VISUAL MONITORING OF PUMPING SYSTEM•TRIENNIAL PIPING INTEGRITY ❑ 5 DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM TEST(0 1 GPM) ❑ 6. TRIENNIAL INTEGRITY TEST(0:1 GPH) SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING). SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): ❑ 7 SELF MONITORING ❑ 7. SELF MONITORING GRAVITY FLOW GRAVITY FLOW(Chack aft that APPIY) ❑ 9 BIENNIAL INTEGRITY TEST(0 1 GPM) ❑ 6 DAILY VISUAL MONITORING ❑ 9 BIENNIAL INTEGRITY TEST(0 1 GPM) SECONDARILY CONTAINED PIPING SECONDARILY CONTAINED PIPING PRESSURIZED PIPING(Chock all that appty) PRESSUP.IZED PIPING(Check aB that apply) 10 CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL ALARMS AND 10.CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL ALARMS AND(check one) Ch k one) AUTO PUMP SHUT OFF WHEN A LEAK OCCURS ❑ a. AUTO PUMP SHUT OFF WHEN A LEAK OCCURS ❑ 0 AUTO PUMP SHUT OFF FOR LEAKS.SYSTEM FAILURE AND SYSTEM ❑ D AUTO PUMP SHUT OFF FOR LEAKS.SYSTEM FAILURE AND SYSTEM DISCONNECTION DISCONNECTION C:1 C. NO AUTO PUMP SHUT OFF ❑ C. NO AUTO PUMP SHUT OFF (y 11 AUTOMATIC LINE LEAK DETECTOR(].0 GPM TEST)WITH FLOW SHUT OFF OR C3 11. AUTOMATIC LEAK DETECTOR RESTRICTION ❑ 12. ANNUAL INTEGRITY TEST(0.t GPH) ❑ 12 ANNUAL INTEGRITY TEST(0 1 GPM) SUCTION/GRAVITY SYSTEM SUCTION/GRAVITY SYSTEM. ❑ 10 CONTINUOUS SUMP SENSOR•AUDIBLE AND VISUAL ALARMS ❑ 10 CONTINUOUS SUMP SENSOR•AUDIBLE AND VISUAL ALARMS EMERGENCY GENERATORS ONLY(Chock as that apply) EMERGENCY GENERATORS ONLY(CAeck aI that aPOW ❑ 14 CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF•AUDIBLE AND ❑ 14 ALARMS CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF•AUDIBLE AND VISUAL VISUAL ALARMS ❑ 15 AUTOMATIC LINE LEAK DETECTOR(0 0 GPM TEST)WITHOUT FLOW SMUT OFF OR ❑ 15 AUTOMATIC LINE LEAK DETECTOR(3 0 GPH TEST) RESTRICTION ❑ 16. ANNUAL INTEGRITY TEST(0 1 GPM) ❑ 16. ANNUAL INTEGRITY TEST(0 1 GPM) ❑ 17. DAILY VISUAL CHECK ❑ 17. DAILY VISUAL CHECK VIII.DISPENSER CONTAINMENT DISPENSER CONTAINMENT ❑ 1. FLOAT MECHANISM THAT SMUTS OFF SHEAR VALVE ❑ 4. DAILY VISUAL CMECK /' C35, TRENCH LINER/MONITORING DATEINSTALLED L]1'[. CONTINUOUS DISPENSER PAN SENSOR•AUDIBLE AND VISUAL ALARMS ❑ 3. CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR DISPENSER-AUDIBLE AND VISUAL ALARMS ❑ 6. NONE IX OWNERIOPERATOR SIGNATURE I ceruty mat the eltormaton provided hamm Is uue and accurau to ate bist at MY khovAed9a L k%'.CL_ SIGNATURE OF OWNE OPERATOR V t DATE NAME OF OWNER;0PERATOR Iphnt) T E OF OWNER/OPERATOR A A n V JCS I� �..�v 0� Perth Eapeauon Date(For local use*MY) Permlt Numoar(For Iota!uae oMy) Pe d Approved(For kXC I use oMY) Formerty SWRCB Form B CUPAFORM(4/99)