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UNIFIED PROGRAM CONSOLIDATED FORM TANKS UNDERGROUND STORAGE TANKS -TANK PAGE 2 VI.PIPING CONSTRUCTION fCheck all met.11) UNDERGROUND PIPING ABOVEGROUND PIPING SYSTEM TYPE ❑L PRESSURE ❑2.SUCTION JK3.GRAVITY 458 ❑L PRESSURE ❑2. SUCTION ❑3.GRAVITY 459 CONSTRUCDON [11.SINGLE WALL ❑3.LINED TRENCH [199.OTHER 460 [11.SINGLE WALL ❑95.UNKNOWN 469 MANUFAMM A2.DOUBLE WALL [195.UNKNOWN ❑2.DOUBLE WALL [199.OTHER MANUFACTURER 461 MANUFACTURER 463 0 1.BARE STEEL [16.FRP COMPATIBLE w/100% METHANOL ❑1.BARE STEEL [16.FRP COMPATIBLE W IWI.METHANOL [12.STAINLESS STEEL [17.GALVANIZED STEEL ❑Unare. ❑2. STAINLESS STEEL [17.GALVANIZED STEEL [13.PLASTIC COMPATIBLE W/CONTENTS [199. Other ❑3. PLASTIC COMPATIBLE W/CONTENTS [18.FLEXIBLE(HDPE) O 99. OTHER PK4.FIBERGLASS [18.FLEXIBLE(HDPE) ❑4. FIBERGLASS ❑9.CATHODIC PROTECTION ❑5.STEEL W/COATING ❑9.CATHODIC PROTECTION 464 ❑5. STEEL W/COATING ❑95.UNKNOWN 465 VII.PIPING LEAK DETECTION Check all that. 1 Amai ormemonimri aheu be aubmitream me local.ea . UNDERGROUND PIPING ABOVEGROUND PIPING SINGLE WALL PIPING a66 SINGLE WALL PIPING 467 PRESSURIZED PIPING(Check all Out apply): PRESSURIZED PIPING(Check all met apply): ❑1.ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP SHUT ❑1. ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP OFF FOR LEAK,SYSTEM FAILURE,AND SYSTEM DISCONNECTION+ SHUT OFF FOR LEAK,SYSTEM FAILURE,AND SYSTEM DISCONNECTION+ AUDIBLE AND VISUAL ALARMS. AUDIBLE AND VISUAL ALARMS. ❑2.MONTHLY 0.2 GPH TEST ❑2. MONTHLY 0.2 GPH TEST ❑3.ANNUAL INTEGRITY TEST(O.IGPH) (3 3.ANNUAL INTEGRITY TEST(O.1GPH) ❑4. DAILY VISUAL CHECK CONVENTIONAL SUCTION SYSTEMS CONVENTIONAL SUCTION SYSTEMS(Check all that apply) ❑5.DAILY VISUAL MONITORING OF PUMPING SYSTEM+TRIENNIAL PIPING 0 5. DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM INTEGRITY TEST(0.1 GPH) 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 ❑7. SELF MONITORING ❑9.BIENNIAL INTEGRITY TEST(0.1 GPH) GRAVITY FLOW(Check all that apply): ❑8. DAILY VISUAL MONITORING ❑9. BIENNIAL INTEGRITY TEST(0.1 GPH) SECONDARILY CONTAINED PIPING SECONDARILY CONTAINED PIPING PRESSURIZED PIPING(Check all that appy): PRESSURIZED PIPING(Check all dart appy): 10. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL 10. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL ALARMS AND(Check one) ALARMS AND(Chink one) [3.. AUTO PUMP SHUT OFF WHEN A LEAK OCCURS ❑e AUTO PUMP SHUT OFF WHEN A LEAK OCCURS ❑b. AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM [I b AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM DISCONNECTION DISCONNECTION 1]c. NO AUTO PUMP SHUT OFF On NO AUTO PUMP SHUT OFF ❑11. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)WI FLOW SHUT 0 11. AUTOMATIC LEAK DETECTOR OFF OR RESTRICTION ❑12. ANNUAL INTEGRITY TEST(0.1 GPH) [112. ANNUAL INTEGRITY TEST(0.1 GPH) SUCTION/GRAVITY SYSTEM SUCDON/GRAVITY SYSTEM 13. CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS ❑13. CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS EMERGENCY GENERATORS ONLY(Check nll mat appy) EMERGENCY GENERATORS ONLY(Cheek 91 wt apply) ❑14. CONTINUOUS SUMP SENSOR WITH AUTO PUMP SHUT OFF" [114. CONTINUOUS SUMP SENSOR WITH AUTO PUMP SHUT OFF" AUDIBLE AND VISUAL ALARMS AUDIBLE AND VISUAL ALARMS ❑15. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)WITH FLOW 0 15. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST) SHUT OFF OR RESTRICTION ❑16.ANNUAL INTEGRITY TEST(0.1 GPH) ❑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 468 [12.CONTINUOUS DISPENSER PAN SENSOR+AUDIBLE AND VISUAL ALARMS ❑5.TRENCH LINER/MONITORING ❑3SPEN ES R1+AUDIBLEDISPENSER AND VISUAL ALARMSAUTO SHUT OFF FOR Ja(6.NONE ,((p oltspe ark 469 IX.OWNER/OPERATOR SIGNATURE 1 atriy tion the information provided herein in we and aaumte W the beat ormy knowlecIp. SIGNATURE OF OWNER/OPERATORDATE 470 NAME OF OWNER/OPRATOR(print) 471 1 TITLE OF OWNER/OPERATOR 472 Pemdt Number(For laal we only) 473 Permit Approved(For local we only) 474 Parnit Expiation Uate(For local we only) 475 UPCF(12/99 revised) 12 Formerly SWRCB Form B