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Sent By: RHL DESIGN GROUP; 7077654503; Jun-19-028:08AM; Page 4)4 UNIFIED PROGRAM CONSOLIDATED FORM TANKS UNDERGROUND STORAGE TANKS - TANK PAGE 2 Poe 2 of 2(removal) - - VI.PIPING CONSTRUCTION iChck.11 mar aI UNDERGROUND PIPING I ABOVEGROUND PIPING SYSTF V TYPE, ❑1.PRESSURE 0 2-SUCTION ❑3.GRAVITY 45R I.PRESSURE 0 2.SUCTION [13.GRAVITY 459. CONSTR UCTIONI 01.SINGLE WALL 03.LINED TRENCH 099.OTHER 4W.. ®1.SINGLE WALL 095.UNKNOWN 4aL i MANUFACTURER 92 DOUBLE WALL 095.UNKNOWN 02.DOUBLE WALT. 099.OTHER MANUFACTURER 461. MANUFACTURER 441 ❑I.RARE STEEL ❑6.FRP COMPATIBLE W1100%METHANOLI ®I.BARE STEEL C16.FRP COMPATIBLE Wf100%SIET'HANOL L STAINLESS STEEL 07.GALVANIZED STEEL ❑2.STAINLESS STEEL 07.GALVANIZED STEEL ®3.PLASTIC COMPATIBLE WITH CONTENTS 095.UNKNOWN ❑3.PLASTIC COMPATIBLE Wr CONTENTS ❑S.FLEXIBLE(HDPE) [199.OTHER ' ❑4.FIBERGLASS 08.FLEXIBLF.(HDPE) ❑99.OTHER [3 4.FIBERGLASS 09.CATHODIC PROTECTION ❑5.STEEL.WICOATING (:19.CATHODIC PROTECTION 4a4. 05.SI LEL W/COATING 095.UNKNOWN 461. VIL PIPING LEAK DETECTION!Cnc:.n mwwWyttAdc<n'Ii dthagemi. um.+wl he mbmnrm mrhelcel, UNDERGROUND PIPING ABOVEGROIRID PIPING SINGLE WALL PIPING .rat SINGLE WALL PIPING PRESSURIZED PIPING(Check all that apply): PRESSURIZED PIPING(Cleck all that apply): ❑L ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP [11. ELECTRONIC LINE.LEAK DETECTOR 3.0 GPH TEST\PITH AUTO PUMP SHM.OFF FOR LEAK,SYSTEM FAILURE,AND SYSTEM DISCONNECTION SHUTOFF FOR LEAK.SYSTEM FAILURE,AND SYSTEM DISCONNECTION ' ANNUAL AND VISUAL ALARMS. t AUDIBLE AND VISUAL ALARMS. 0 2. MONTHLY 0.2 GPH TEST 02. MONTHLY 0.2 GPH TEST [33. ANNUAL INTEGRITY TEST(0.1 OFF) 03. ANNUAL INTEGRITY TEST(0.1 GPH) [14. DAILY VISUAL CHECK CONVENTIONAL SUCTION SYSTEMS CONVENTIONAL SUCTION SYSTEMS(Check all that apply) 0 S. DAILY VISUAL MONITORING OF PUMPING SYSTEM+TRIENNIAL.PIPING I [35. DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM INTEGRITY TEST(0.I GPH) SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): [16. TRIENNIAL INTEGRITY TEST(0.1 GPII) ' [37. SELF MONITORING SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPINGI- GRAVITY FLOW 07. SELF MONITORING 9. BIENNIAL INTEGRITY ITST(0.1 GPH) GRAVITY FLOW(Check all that apply). ❑& DAILY VISUAL MONITORING 09. BIENNIAL INTEGRITY TEST(0.1 GPH) SECONDARILY CONTAINED PIPING SECONDARILY CONTAINED PIPING PRESSURIZED PIPING(Check 311 that IPPly): PRESSURIZED PIPING(Cheek all dual apply): 10. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL 10, CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL ALARMS ANO IChee-k ane) ALARMS AND(Check one) ❑a.AUTO PUMP SHUT OFF WHEN A LEAK OCCURS [3.. AUTO PUMP SHUT OFF WHEN A LEAK OCCURS Ob.AUTO PUMP SHUT OFF FOR LEAKS.SYSTEM FAILURE AND SYSTEM ❑b. AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM DISCONNECTION DISCOCPIECTION 0e. NO AUTO PUMP SHUT OFF 0c. NO AUTO PUMP SHUT OFF O 11. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)ZIT11 FLOW SHUT 0 11 AUTOMATIC LEAK DETECTOR OFF OR RESTRICTION ❑12. ANNUAL INTEGRITY TEST(0.1 GPH) 0 12.ANNUAL DITEGR3TY TEST(0.1 GPH) SUCTION/GRAVITY SYSTEM SUCTION/GRAVITY SYSTEM 013. CONTINUOUS SUIMP SENSOR t AUDIBLE AND VISUAL ALARMS 013.CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS EMERGENCY GENERATORS ONLY(Check all Thal apply) EMERGENCY GENERATORS ONLY(Check all that apply) 014. CONTINUOUS SUMP SENSOR WITHOU AUTO PUMP SHL70FT 014,CONTINUOUS SUMP SENSOR WITHOU AUTO PUMP SHUT OFF AUDIBLE AND VISUAL ALARMS AUDIBLE AND VISUAL ALARMS 015. AUTOMATIC LINE LEAK DETECTOR (3.0 GPH TEST) wiTHoo FLOW [115.AUTOMATIC UNE LEAK DETECTOR(3.0 GPH TEST) SHUT OFF OR RESTRICTION ❑16. ANNUAL INTEGRITY TEST(0.1 GPH) [116.ANNUAL INT'CGNI'lY TEST(0.1 GPH) 017. DAILY VISUAL CHECK 0 17. DAILY VISUAL CHECK VIII.DISPENSER CONTAINMENT DISPENSER CONTAINMENT 461. 01. FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE ❑4. DAILY VISUAL CHECK w9. DATE INSTALLED 02. CONTINUOUS DISPENSER PAN SENSOR r AUDIBLE AND VISUAL ALARMS 05. TRFNCK'I,INF,R MONITORING 03. CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR 06. NONE DISPENSER+AUDIBLE AND VISUAL ALARMS IN.OWNERIOPERATOR SIGNATURE I certify that the information provided berein is hue and accurale to the 6w of my knowledge. SIGNATURE OF OWNERIOPERATOR DATE: a:o. NAME OF OWNER'OPERATOR(ptim): Scott Tanlle13111 TITLE OF OWNERrOPERATOR: Agent for Pacific Bell cr. Permit Number(Agmry a.e only) 473. 1 Ptmnk Appna d By(Agency use W IY) 474. 1 Pumtt EapinOon Date(Agency u.e m1y) 05. UPCF hwfwrc-b(1199)-374 hup:llwww.uuldcxmorg Rev.02/16/00