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UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERSOUND STORAGE TANKS - NK PAGE 2 TANK <br /> VI.PIPING CONSTRUCTION(check en that apply) Page_ or <br /> UNDERGROUND PIPING ABOVEGROUND PIPING <br /> SYSTEM TYPE 191.PRESSURE 02 SUCTION 03.GRAVITY 459 01.PRESSURE D2. SUCTION 03.GRAVITY 459 <br /> CONSTRUCTION/ 0 1.SINGLE WALL C 3.UNED TRENCH 0 99.OTHER 460 0 1.SINGLE WALL ❑95.UNKNOWN 462 <br /> MANUFACTURER 02.DOUBLE WALL 095.UNKNOWN 02.DOUBLE WALL 099.OTHER <br /> MANUFACTURER TelefleX 461 MANUFACTURER 463 <br /> 01.BARE STEEL 0 6.FRP COMPATIBLE w1ion MER4Wol ❑1.BARE STEEL 0 6.FRP COMPATIBLE WIIO6%MEHANCL <br /> 0 2.STAINLESS STEEL 0 7.GALVANIZED STEEL 0 UKNOWN ❑2 STAINLESS STEEL 0 7.GALVANIZED STEEL <br /> 03.PLASTIC COMPATIBLE W1 CONTENTS 099. OTHER 03. PLASTIC COMPATIBLE WI CONTENTS D 8.FLEXIBLE(HOPE) 099. OTHER <br /> 04.FIBERGLASS O S.FLEXIBLE(HDPE) 04. FIBERGLASS 09.CATHODIC PROTECTION <br /> 0 S.STEEL WICOATING 0 9.CATHODIC PROTECTION 464 0 5. STEEL W/COATING 0 95.UNKNOWN 465 <br /> VII.PIPING LEAK DETECTION(Check all Ihat apPl )(A tleacri ion of the monitoring program ahall be submitted to the local agenc) <br /> UNDERGROUND PIPING ABOVEGROUND PIPING <br /> SINGLE WALL PIPING 466 SINGLE WALL PIPING 467 <br /> PRESSURIZED PIPING(Checkal thatapply): PRESSURIZED PIPING(Check all that apply): <br /> 01. ELECTRONIC UNE LEAK DETECTOR 3.0 GPM TEST WITH AUTO PUMP SHUT OFF FOR 01. ELECTRONIC LINE LEAK DETECTOR 3.0 GPM TEST WITH AUTO PUMP SHUT OFF FOR <br /> LEAK,SYSTEM FAILURE,AND SYSTEM DISCONNECTION*AUDIBLE AND VISUAL LEAK SYSTEM FAILURE,AND SYSTEM DISCONNECTION*AUDIBLE AND VISUAL <br /> ALARMS. ALARMS. <br /> 132 MONTHLY 0.2 GPM TEST Cl 2. MONTHLY 0.2 GPM TEST <br /> 03. ANNUAL INTEGRITY TEST(0.1GPH) 03. ANNUAL INTEGRITY TEST(0.1GPH) <br /> 04. DAILY VISUAL CHECK <br /> CONVENTIONAL SUCTION SYSTEMS CONVENTIONAL SUCTION SYSTEMS(Check an that appry) <br /> 05. DAILY VISUAL MONITORING OF PUMPING SYSTEM.TRIENNIAL PIPING INTEGRITY <br /> TEST(0.1 GPM) 05. DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM <br /> SAFE SUCTION SYSTEMS(NO VALUES IN BELOW GROUNDPIPING): 0 6. TRIENNIAL INTEGRITY TEST(0.1 GPM) <br /> 07. SELFMONITORING SAFE SUCTION SYSTEMS(NO VALVES.IN BELOW GROUND PIPING): <br /> GRAVITY FLOW [17. SELF MONITORING <br /> 09. BIENNIAL INTEGRITY TEST(0.1 GPM) GRAVITY FLOW(Check all that appry): <br /> 08. DAILY VISUAL MONITORING <br /> 09. BIENNIAL INTEGRITY TEST(0.1 GPM) <br /> SECONDARILY CONTAINED PIPING SECONDARILY CONTAINED PIPING <br /> PRESSURIZED PIPING(Check all Mat apply): PRESSURIZED PIPING(Check all Mat apply): <br /> 10. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL ALARMS AND 10. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL ALARMS AND <br /> (Check one) (Check one) <br /> Da AUTO PUMP SHUT OFF WHEN A LEAK OCCURS 0 a AUTO PUMP SHUT OFF WHEN A LEAK OCCURS <br /> 0 b. AUTO PUMP SHUT OFF FOR LEAKS.SYSTEM FAILURE AND SYSTEM Ob AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM <br /> DISCONNECTION DISCONNECTION <br /> ®c. NOAUTO PUMP SHUT OFF Dc NOAUTO PUMP SHUT OFF <br /> 011. AUTOMATIC LINE LEAK DETECTOR(3.0 GPM TEST)NTH FLOW SHUTOFF OR <br /> RESTRICTION 011 AUTOMATIC LEAK DETECTOR <br /> 012. ANNUAL INTEGRITY TEST(0.1 GPM) 012. ANNUAL INTEGRITY TEST(0.1 GPH)l <br /> SUCTIOWGRAMTY SYSTEM SUCTIONIGRAVITY SYSTEM <br /> 013. CONTINUOUS SUMP SENSOR+AUDIBLE ANDVISUAL ALARMS 013. CONTINUOUS SUMP SENSOR-AUDIBLE ANDVISUALALARMS <br /> EMERGENCY GENERATORS ONLY(Check all Mat apply) EMERGENCY GENERATORS ONLY(Check all that apply) <br /> 014. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF-AUDIBLE AND 014. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF..AUDIBLE AND <br /> VISUALALARMS VISUALALARMS <br /> 015. AUTOMATIC LINE LEAK DETECTOR(3.0 GPM TEST)WITHO FLOW SHUT OFF OR [115. AUTOMATIC LINE LEAK DETECTOR(3.0 GPM TEST <br /> RESTRICTION - ) <br /> 0 16, ANNUAL INTEGRITY TEST(0.1 GPM) 016. ANNUAL INTEGRITY TEST 10.1 GPM) <br /> 017. DAILY VISUAL CHECK 017. DAILYVISUAL CHECK <br /> VIII.DISPENSER CONTAINMENT <br /> DISPENSER 01. FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE <br /> CONTAINMENT ❑4.DAILY VISUAL CHECK <br /> DATEINSTALLED 466 02. CONTINUOUS DISPENSER PAN SENSOR.AUDIBLE AND VISUAL ALARMS 05.TRENCH LINER I MONITORING <br /> 1998 03. CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR DISPENSER• O6.NONE 469 <br /> AUDIBLE AND VISUAL ALARMS . <br /> IX.OWNER/OPERATOR SIGNATURE <br /> I certify that the infortna' n pr video in is e d accurate to the best of my knowledge. <br /> b[UNATUREU DATE 470 <br /> 1/25/02 <br /> NAME OF OWN OPRATOR(print) TITLE OF OWNERIOPERATOR 472 <br /> Dennis Smith Operations & Environmental Specialist <br /> Permit Number(For local use only) 473 Permit Approved(For local use only) Permit Expiration Date(For local use only) <br /> 475 <br /> UPCF(1/99 revised) Formerly SWRCB Form B <br />