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UNIFIED PROGRAM CONSOLIDATED FORM UNDER OUND STORAGE TANKS ANK PAGE 2 TANK A.PIPING CONSTRUCTION(Check all that apply) Page_ or UNDERGROUND PIPING ABOVEGROUND PIPING SYSTEM TYPE ®1.PRESSURE ❑2 SUCTION ❑3.GRAVITY 458 ❑1.PRESSURE - ❑2. SUCTION ❑3.GRAVITY 459 CONSTRUCTION/ ❑1.SINGLE WALL ❑3.LINED TRENCH ❑99.OTHER 460 ❑1.SINGLE WALL ❑95.UNKNOWN 462 MANUFACTURER 02.DOUBLE WALL ❑95.UNKNOWN ❑2.DOUBLE WALL ❑99.OTHER MANUFACTURER TelefleX 461 MANUFACTURER 963 ❑1.BARE STEEL ®6.FRP COMPATIBLE w1100% METHANOL ❑1.BARE STEEL ❑6.FRP COMPATIBLE yinom METHANOL ❑2 STAINLESS STEEL ❑7.GALVANIZED STEEL ❑UKNOWN ❑2. STAINLESS STEEL ❑7.GALVANIZED STEEL ❑3.PLASTIC COMPATIBLE W/CONTENTS ❑99. OTHER ❑3. PLASTIC COMPATIBLE W/CONTENTS ❑8.FLEXIBLE(HDPE) ❑99. OTHER ❑4.FIBERGLASS ❑8.FLEXIBLE(HOPE) 0 4. FIBERGLASS 0 9.CATHODIC PROTECTION - ❑S.STEEL W/COATING ❑9.CATHODIC PROTECTION 464 ❑5. STEEL WICOATING ❑95.UNKNOWN 465 VII.PIPING LEAK DETECTION Check all Nat 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 UNE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP SHUT OFF FOR ❑1. ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP SHUT OFF FOR LEAK SYSTEM FAILURE,AND SYSTEM DISCONNECTION*AUDIBLE AND VISUAL LEAK SYSTEM FAILURE,AND SYSTEM DISCONNECTION.AUDIBLE AND VISUAL ALARMS. ALARMS. ❑2. MONTHLY 0.2 GPH TEST ❑2. MONTHLY 0.2 GPH TEST 03. ANNUAL INTEGRITY TEST(O.1GPH) 03. ANNUAL INTEGRITY TEST(0.1GPH) ❑4. DAILY VISUAL CHECK CONVENTIONAL SUCTION SYSTEMS CONVENTIONAL SUCTION SYSTEMS(Check ad Nztapply) 135. DAILY VISUAL MONITORING OF PUMPING SYSTEM.TRIENNIAL PIPING INTEGRITY TEST(0.1 GPH) [35. DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM SAFE SUCTION SYSTEMS(NO VALUES IN BELOW GROUNDPIPING): 06. TRIENNIAL INTEGRITY TEST(0.1 GPH) ❑7. SELF MONITORING SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): GRAVITY FLOW ❑7. SELF MONITORING ❑9. BIENNIAL INTEGRITY TEST(0.1 GPH) GRAVITY FLOW(Chad all Natapply): 08. 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 ail that apply): 10. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE ANDVISUAL ALARMS AND 10. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL ALARMS AND (Check ore) (Chick 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 ❑b AUTO PUMP SHUT OFF FOR LEAKS.SYSTEM FAILURE AND SYSTEM DISCONNECTION DISCONNECTION Sc. NOAUTO PUMP SHUT OFF ❑c NOAUTOPUMPSHUTOFF 011. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST) LTH FLOW SHUTOFF OR RESTRICTION 011. AUTOMATIC LEAK DETECTOR ®12. ANNUAL INTEGRITY TEST(0.1 GPH) ❑12. ANNUAL INTEGRITY TEST(0.1 GPA) SUCTION/GRAVITY SYSTEM SUCTION/GRAVITY SYSTEM 013. CONTINUOUS SUMP SENSOR-AUDIBLE AND VISUAL ALARMS 013. 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 ALTO PUMP SHUT OFF.AUDIBLE AND 014. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF.AUDIBLE AND VISUALALARMS VISUALALARMS ❑15.AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)WITHOUT FLOW SHUT OFF OR 15. AUTOMATIC LINE LEAK DETECTOR 3 0 GPH TES RESTRICTION ( T) [116. ANNUAL INTEGRITY TEST(0.1 GPH) ❑16. ANNUAL INTEGRITY TEST 10.1 GPH) ❑17. DAILY VISUAL CHECK ❑17. DAILY VISUAL CHECK VIII.DISPENSER CONTAINMENT DISPENSER ®1. FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE CONTAINMENT ❑4.DAILY VISUAL CHECK DATEINSTALLED 466 ❑2. CONTINUOUS DISPENSER PAN SENSOR.AUDIBLE AND VISUAL ALARMS ❑5.TRENCH LINER I MONITORING 1998 ❑3. CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR DISPENSER. �6.NONE 469 AUDIBLE ANDVISUAL ALARMS IX.OWNER/OPERATOR SIGNATURE I wrlify that the inrormatio pro dad hereis" n aerate to the bast of my knowledge. SIGNATURE E R DATE 470 1/25/02 NAM EOFOWNERIOPRATOR(pdnt) TITLE OF OWNER/OPERATOR 472 Dennis Smith Operations & Environmental Specialist Permit Number(For local use only) 473 Permit Approved(Far[owl use only) Permit Expiration Data(For local use only) 475 UPCF(1/99 revised) Formerly SWRCB Form B