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UNIFIED PROGRAM CONSOLIDATED FORM <br /> TANKS <br /> UNDERGROUND STORAGE TANKS - TANK PAGE 2 <br /> VI.PIPING CONSTRUCTION Checker howl Page of <br /> UNDERGROUND PIPING I ABOVEGROUND PIPING <br /> SYSTEM TYPE 1A 1.PRESSURE 0 2.SUCTION 0 3.GRAVITY 21 <br /> 0 1.PRESSURE [12. SUCTION [13.GRAVITY 459 <br /> CONSTRUCTION y0`1 1.SINGLE WALL 0 3.LINED TRENCH [199.OTHER 460 ❑1.SINGLE WALL 95.UNKNOWN 462 <br /> MANUFACTURER C 2.DOUBLE WALL 0 95.UNKNOWN ❑2.DOUBLE WALL ❑99.OTHER <br /> MANUFACTURER MI MANUFACTURER 463 <br /> ❑1.BARE STEEL 06.FRP COMPATIBLE W/100% METHANOL 01.BARE STEEL 06.FRP COMPATIBLE W/100%METHANOL <br /> ❑2.STAINLESS STEEL 0 7.GALVANIZED STEEL 0 Unknown 0 2. STAINLESS STEEL [17.GALVANIZED STEEL <br /> 0 3.PLASTIC COMPATIBLE W/CONTENTS [199. Other ❑7. PLASTIC COMPATIBL W/CONTENTS 0 S.FLEXIBLE(HDPE) [199. OTHER <br /> 0 4.FIBERGLASS [18.FLEXIBLE(HDPE) ❑4. FIBERGLASS [19.CATHODIC PROTECTION <br /> 0 5.STEEL W/COATING 0 9.CATHODIC PROTECTION 464 0 5. STEEL W/COATING 0 95.UNKNOWN 465 <br /> VII.PIPING LEAK DETECTION(Check all mat 1 Adeacrironofthe tnoulmrin ro,,ram shoo beaubmined to the lacelen <br /> UNDERGROUND PIPING ABOVEGROUND PIPING <br /> SINGLE WALL PIPING 466 SINGLE WALL PIPING 467 <br /> PRESSURIZED PIPING(Check all that apply): PRESSURIZED PIPING(Cheek 01 mu apply): <br /> 0 1.ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP SHUT 0 1. ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP <br /> OFF FOR LEAK,SYSTEM FAILURE,AND SYSTEM DISCONNECTION+ SHUT OFF FOR LEAK,SYSTEM FAILURE,AND SYSTEM DISCONNECTION+ <br /> AUDIBLE AND VISUAL ALARMS. AUDIBLE AND VISUAL ALARMS. <br /> 0 2.MONTHLY 0.2 GPH TEST [32. MONTHLY 10.2 GPH TEST <br /> 0 3.ANNUAL INTEGRITY TEST(O.1GPH) 0 3.ANNUAL HTrEGRITY TEST(O.1GPH) <br /> 04. DAILY VIS'i' <br /> AL CHECK <br /> CONVENTIONAL SUCTION SYSTEMS CONVENTIONALSUCTION SYSTEMS(Check all that apply) <br /> 0 5.DAILY VISUAL MONITORING OF PUMPING SYSTEM+TRIENNIAL PIPING S. DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM <br /> INTEGRITY TEST(RI GPH) <br /> SAFE SUCTION SYSTEMS(NO VALUES IN BELOW GROUNDPIPING): 0 6. TRIENNIALI INTEGRITY TEST(0.1 GPH) <br /> 0 7.SELF MONITORING SAFE SUCTION SKSTEMS(NO VALVES IN BELOW GROUND PIPING): <br /> GRAVITY FLOW 07. SELF MONITORING <br /> 0 9.BIENNIAL INTEGRITY TEST(0.1 GPH) GRAVITY FLOW(Check all thatapply): <br /> [18. DAILY VISUAL MONITORING <br /> 0 9. BIENNIAL INTEGRITY TEST(0.1 GPH) <br /> SECONDARILY CONTAINED PIPING SECONDARILY CONTAINED PIPING <br /> PRESSURIZED PIPING(Check ell shay apply): PRESSURIZED PIPING(Check all that apply): <br /> 10. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL 10. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL <br /> ALARMS AND(Check one) ALARMS AND(Check one) <br /> 0 a. AUTO PUMP SHUT OFF WHEN A LEAK OCCURS 0 a AUTO PUMP SHUT OFF WHEN A LEAK OCCURS <br /> 0 Is. AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM Elle AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM <br /> DISCONNECTION DISCONNECTION <br /> On. NO AUTO PUMP SHUT OFF Oc NO AUTO PUMP SHUT OFF <br /> �J 11. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)WITH FLOW SHUT O 11 AUTOMATIC LEAK DETECTOR <br /> OFF OR RESTRICTION <br /> 12. ANNUAL INTEGRITY TEST(0.1 GPH) 0 12. ANNUAL INTEGRITY TEST(0.1 GPH) <br /> SUCTION/GRAVITY SYSTEM SUCTION/GRAVITY SYSTEM <br /> 0 13. CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS [113. CON'TMUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS <br /> EMERGENCY GENERATORS ONLY(Check all that apply) EMERGENCY GENERATORS ONLY(Chock all that apply) <br /> ❑14. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF' 0 14. CONTINUOUS SUMP SENSOR WITHOIIT AUTO PUMP SHUTOFF <br /> AUDIBLE AND VISUAL ALARMS AUDIBLE AND VISUAL ALARMS <br /> ❑15. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)WITHOUT FLOW [115. AUTOMATIC LME LEAK DETECTOR(3.0 GPH TEST) <br /> SHUT OFF OR RESTRICTION <br /> ❑16.ANNUAL INTEGRITY TEST(0.1 GPH) ❑16.ANNUAL INTEGRITY TEST(0.1 GPH) <br /> 017. DAILY VISUAL CHECK ❑17. DAILY VISUAL CHECK <br /> VIII.DISPENSER CONTAINMENT <br /> DISPENSER CONTAINMENT [11.FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE 0 4.DAILY VISUAL CHECK <br /> DATEINSTALLED 40 02.CONTINUOUS DISPENSER PAN SENSOR+AUDIBLE AND VISUAL ALARMS 05.TRENCH LINER/MONITORING <br /> [13.CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR 0 6.NONE 464 <br /> DISPENSER+AUDIBLE AND VISUAL ALARMS <br /> IX.OWNER/OPERATOR SIGNATURE <br /> enify thauhe inf mwe'mvided cministrucand=omtcwmebestofmykwwledge. <br /> RE F R/O TOR DATE 470 <br /> ME OF R/O TOR ri Q 4]I E OFOV. WO1�I1RA=V ( 4]2 <br /> Permit Number or local use only) 473 Permit Approved(Fm local use only) }� 474 Permit Expiration Dam(Far Iwai use a ly 475 <br /> UPCF(12/99 revised) 12 Formerly SWRCB Form B <br />