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�.. VO, UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANKS - TANK PAGE 2 TANKS VL PIPING CONSTRUCTION Check At rhnta1 UNDERGROUND PIPING P.V 2 or_ SYSTEM TYPE ❑1.PRESSURE to12.SUCTIONABOVEGROUND PIPING 4 ❑3.GRAVITY 458 ❑1.PRE CONSSSURE ❑2. SUCTION ❑3.GRAVITY 459 TRUC]'ION ❑1.SINGLE WALL ❑3.LINED TRENCH ❑99.OTHER 460 ❑1.SINGLE WALL MANUFACTURER X2.DOUBLE WALL E]95.UNKNOWN ❑2.DOUBLE WALL 11 95.Oa62 MANUFACTURER 1199.OTTHERHER 46l MANUFACTURER 463 ❑1.BARE STEEL [16.FRP COMPATIBLE w/loos METHANOL ❑1,BARE STEEL ❑2.STAINLESS STEEL [17. ❑6.FRP COMPATIBLE k11THANOL GALVANIZED STEEL ❑UNmoum [12. STAINLESS STEEL [17.GALVANIZED STEELL 113.PLASTIC COMPATIBLE W/CONTENTS ❑99. Other ❑3, PLASTIC COMPATIBLE W/CONTENTS ❑8,FLEXIBLE(HDPE) ❑99, OTHER �,4.FIBERGLASS ❑8.FLEXIBLE(HDPE) ❑4. FIBERGLASS E3 9.CATHODIC PROTECTION [15.STEEL W/COATING ❑9.CATHODIC PROTECTION 464 ❑5. STEEL W/COATING D 95 UNKNOWN 465 VII.PIPING LEAK DETECTION cheek all that. 1 A dacni on afthe mowbrin pro,,arn shall w wbmined to d¢local. UNDERGROUND PIPING ABOVEGROUND PIPING SINGLE WALL PIPING 466 SINGLE WALL PIPING 467 PRESSURIZED PIPING(Check all that apply): PRESSURIZED PIPING(Check.11 th.t.pply): ❑1.ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP SHUT Ell. ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST AUTOPUMP OFF FOR LEAK,SYSTEM FAILURE,AND SYSTEM DISCONNECTION+ SHUT OFF FOR LEAK,SYSTEM FAILURE,AND SYSTEDISCONNECTION+ AUDIBLE AND VISUAL ALARMS. AUDIBLE AND VISUAL ALARMS. ❑2.MONTHLY 0.2 GPH TEST [12. MONTHLY 0.2 GPH TEST [13.ANNUAL INTEGRITY TEST(0.1GEN) ❑3.ANNUAL INTEGRITY TEST(0.IGPH) ❑4. DAILY VISUAL CHECK CONVENTIONAL SUCTION SYSTEMS CONVENTIONAL SUCTION SYSTEMS(Chock all tM1u apply) ❑5.DAILY VISUAL MONITORING OF PUMPING SYSTEM+TRIENNIAL PIPING INTEGRITY TEST(0.1 GPH) El 5. DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM SAFE SUCTION SYSTEMS(NO VALUES IN BELOW GROUNDPIPING): ❑6. TRIENNIAL INTEGRITY TEST(0.1 GPH) ❑7.SELF MONITORING SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): GRAVITY FLOW [17. SELF MONITORING ❑9.BIENNIAL INTEGRITY TEST(0.1 GPH) GRAVITY FLOW(Check an tion apply): ❑8. DAILY VISUAL MONITORING ❑9. BIENNIAL INTEGRITY TEST(0.1 GPH) SECONDARILY CONTAINED PIPING SECONDARILY CONTAINED PIPING PRESSURIZED PIPING(Chcckall that apply): PRESSURIZED PIPING(Check a0 cwt apply): 10. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL 10. CONTINUOUS TURBINE SUMP SENSOR MM AUDIBLE AND VISUAL ALARMS AND(CTedr one) ALARMS AND(Check am) ❑n. 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 [3 b AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM DISCONNECTION DISCONNECTION �c. NO AUTO PUMP SHUT OFF C]c NO AUTO PUMP SHUT OFF ❑11. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST) VWI'DI FLOW SHUT OFF OR RESTRICTION ❑11. AUTOMATIC LEAK DETECTOR ❑12. ANNUAL INTEGRITY TEST(0.1 GPH) ❑12. ANNUAL INTEGRITY TEST(0.1 GPH) SUCTION/GRAVITY SYSTEM SUCTIONMRAVITY SYSTEM 13. CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS ❑13. CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS EMERGENCY GENERATORS ONLY(Clunk 41 twc.pply) EMERGENCY GENERATORS ONLY(chenlr at that apply) 14. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF [114. CONTINUOUS SUMP SENSOR WITH AUTO PUMP SHUT OFF a AUDIBLE AND VISUAL ALARMS AUDIBLE AND VISUAL ALARMS ❑15. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)WITH FLOW [115. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST) SHUT OFF OR RESTRICTION ❑16.ANNUAL INTEGRITY TEST(0.1 GPID ❑16.ANNUAL INTEGRITY TEST(0.1 GPH) (]17. DAILY VISUAL CHECK ❑17. DAILY VISUAL CHECK VIII.DISPENSER CONTAINMENT DISPENSER CONTAINMENT ❑1.FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE ❑4.DAILY VISUAL CHECK DATE INSTALLED 46a ❑2.CONTINUOUS DISPENSER PAN SENSOR+AUDIBLE AND VISUAL ALARMS ❑5.TRENCH LINER/MONITORING ❑3.CONTINUOUS ER+AUDIBLE DISPENSER VISUALSENSOR MS AUTO SHUT OFF FOR (K6.NONE NpT(a,J Foe-40469 DISPENIX.OWNER/OPERATOR SIGNATURE 1 cetiy twtthc ianomatioa pr,,A Whereini.toe and accurate o tw beat o(my knowledge. SIGNATURE OF OWNER/OPERATOR DATE 470 NAME OF OWNER/OPRATOR(print) 471 1 TITLE OF OWNER/OPEKATOR 472 Permit Numhn(Fm Ictal ase only) 473 Permil Approved(For local use only) 474 Permit Expiration Date(For local use only) 475 UPCF(12/99 revised) 12 Formerly SWRCB Form B