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UNIFIED PROGRAM CONSOLIDATED FORM UNDER UND STORAGE TANKS - IRK PAGE 2 TANK VI.PIPING CONSTRUCTION(Cheat an that appy) Page_of UNDERGROUND PIPING ABOVEGROUND PIPING SYSTEM TYPE ®1.PRESSURE ❑2.SUCTION ❑3.GRAVITY 456 ❑1.PRESSURE ❑2. SUCTION ❑3.GRAVITY 456 CONSTRUCTION/ ❑1.SINGLE WALL ❑3.UNED TRENCH ❑99.OTHER 460 ❑1.SINGLE WALL ❑95.UNKNOWN. 462 MANUFACTURER 02.DOUBLE WALL [195,UNKNOWN ❑Z DOUBLE WALL ❑99.OTHER MANUFACTURER TelefleX 461 MANUFACTURER 467 ❑1.BARE STEEL ®6.FRP COMPATIBLE w/100-METHANOL ❑1.BARE STEEL ❑6.FRP COMPATIBLE W1100%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 ❑B.FLEXIBLE(HDPE) 1199. OTHER ❑4.FIBERGLASS ❑B.FLEXIBLE(HDPE) 0 4. FIBERGLASS ❑9.CATHODIC PROTECTION ❑5.STEEL W/COATING ❑9.CATHODIC PROTECTION 464 ❑5. STEEL WICOATING ❑95.UNKNOWN 465 VII.PIPING LEAK DETECTION(check an that apply)(A aeecription of the monitodng PMllrem shall be submitted to he local agency.) UNDERGROUND PIPING ABOVEGROUND PIPING SINGLE WALL PIPING 466 SINGLE WALL PIPING 467 PRESSURIZED PIPING(Check an that apply): PRESSURIZED PIPING(Cheat 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.AUDI8LE AND VISUAL ALARMS. ALARMS. 112. MONTHLY 0.2 GPH TEST 112. MONTHLY 0.2 GPH TEST 03. ANNUAL INTEGRITY TEST(0.1GPH) 03. ANNUAL INTEGRITY TEST(0.1GPH) 04. DAILY VISUAL CHECK CONVENTIONAL SUCTION SYSTEMS CONVENTIONAL SUCTION SYSTEMS(Check all that apply) 05. DAILY VISUAL MONITORING OF PUMPING SYSTEM-TRIENNIAL PIPING INTEGRITY TEST(0.1 GPH) 115. DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM SAFE SUCTION SYSTEMS(NO VALUES IN BELOW GROUNDPIPING): ❑6. TRIENNIAL INTEGRITY TEST(0.1 GPH) 07. SELFMONITORING SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): GRAVITY FLOW [17. SELFMONITORING ❑9. BIENNIAL INTEGRITY TEST(0.1 GPH) GRAVITY FLOW(Cneck an that apply): 118. DAILY VISUAL MONITORING 9. BIENNIAL INTEGRITY TEST(0.1 GPH) SECONDARILY CONTAINED PIPING SECONDARILY CONTAINED PIPING PRESSURIZED PIPING(Cheat an mat apply): PRESSURIZED PIPING(Cheat all mat 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) (Check ane) ❑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 ®c. NOAUTO PUMP SHUT OFF Elc NOAUTO PUMP SHUT OFF ❑11. AUTOMATIC UNE LEAK DETECTOR(3.0 GPH TEST)WITH FLOW SHUTOFF OR RESTRICTION 011. AUTOMATIC LEAK DETECTOR ®12. ANNUAL INTEGRITY TEST(0.1 GPH) [112. ANNUAL INTEGRITY TEST(0.1 GPH) I SUCTION/GRAVITY SYSTEM SUCTIOWGRAVITY SYSTEM ❑13. CONTINUOUS SUMP SENSOR.AUDIBLE AND VISUAL ALARMS 013. CONTINUOUS SUMP SENSOR+AUDIBLE ANDVISUALALARMS EMERGENCY GENERATORS ONLY(Cheat all that apply) EMERGENCY GENERATORS ONLY(Check all that apply) 014. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF.AUDIBLE AND ❑14. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF.AUDIBLE AND MSUALALARMS VISUALALARMS ❑15.AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)WITHOUT FLOW SHUT OFF OR RESTRICTION 15. AUTOMATIC UNE LEAK DETECTOR(3.0 GPH TEST) ❑16. ANNUAL INTEGRITY TEST(0.1 GPH) [116. ANNUAL INTEGRITY TEST(0.1 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 05.TRENCH UNER/MONITORING 1998 03. CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR DISPENSER. �6.NONE 469 AUDIBLE AND VISUAL ALARMS IX.OWNER/OPERATOR SIGNATURE I certify mat he inform on owde W ein is and accurate to me best of my knowledge. SIGNATOR T DATE 470 1/25/02 NAME OF OW R/OPRATOR(print) TITLE OF OWNERIOPERATOR 472 Dennis Smith Operations& Environmental Specialist Permit Number(For local use only) 473 Permit Approved(Far local use only) Permit Expiration Date(Far local use only) 475 UPCF(1/99 revised) Formerly SWRCB Form 6