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r , UN IED PROGRAM CONSOLIDATED FORM TANKS UNDERGROUND STORAGE TANKS -TANK PAGE 2 VI.PIPING CONSTRUCTION(CheckMfhauppq UNDERGROUND PIPING ABOVEGROUND PIPING SYSTEM TYPE ❑ 1 PRESSURE C12. SUCTION ❑ 3. GRAVITY ❑ L PRESSURE C31 SUCTION [31 GRAVITY CONSTRUCTIOW ❑ t. SINGLE WALL C33. LINED TRENCH ❑N. OTHER ❑ 1. SINGLE WALL ❑95. UNKNOWN MANUFACTURER ❑ 2. DOUBLE WALL ❑95. UNKNOWN ❑ 2. DOUBLE WALL ❑99. OTHER MANUFACTURER MANUFACTURER ❑ 1.BARE STEEL ❑ 5. FRP COMPATIBLE W/1011%METHANOL ❑ 1. BARE STEEL ❑ 5. FRP COMPATIBLE WI 1W%METHANOL MATERIALS AND ❑ 2. STAINLESS STEEL ❑ T. GALVANIZED STEEL ❑ 2. STAINLESS STEEL ❑ T. GALVANIZED STEEL CORROSION 13PROTECTION 3. PLASTIC COMPATIBLE WITH CONTENT$ 095. UNKNOWN ❑ 3. PLASTIC COMPATIBLE WITH CONTENTS ❑ B. FLE%IBIE(HOPE) 099. OTHER ❑ a. FIBERGLASS ❑ B. FLEXIBLE(HOPE) ❑W. OTHER ❑ a. FIBERGUSS ❑ S.CATHODIC PROTECTION ❑ 5. STEEL W/COATING ❑ 9. CATHODICPROTECTION ❑ 5. STEEL W/COATING ❑95. UNKNOWN W.PIPING LEAK DETECTION(Check a8 that appy) UNDERGROUND PIPING ABOVEGROUND PIPING SINGLE WALL PIPING SINGLE WALL PIPING PRESSURIZED PIPING(Cheek aN that apply): PRESSURIZED PIPING(Cheek all that appy): ❑ 1. ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP SHUT OFF FOR ❑ 1. ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WMTH AUTO PUMP SHUT OFF FOR LEAK, LEAK SYSTEM FAILURE,AND SYSTEM DISCONNECTION+AUDIBLE AND VISUAL SYSTEM FAILURE AND SYSTEM DISCONNECTION+AUDIBLE AND VISUAL ALARMS ALARMS ❑ 2. MONTHLA ❑ 3.AN Y0.2GPH TEST 11 2.ANNUAL MONTHLYUAL GPH TEST INTEITYTEST(0.1 GPM) C113 d. DAILY VISUAL 3. ANNUAL INTEGRITY MET(0.1 GPH) VISUAL CHECK CONVENTIONAL SUCTION SYSTEMS: CONVENTIONAL SUCTION SYSTEMS(Cheer ap t/wtappiy: ❑ 5. DAILY VISUAL MONITORING OF PUMPING SYSTEM+TRIENNIAL PIPING INTEGRITY ❑ S. DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM TESTJDI GPH) ❑ B. TRIENNIAL INTEGRITY MST(0.1 GPH) SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): ❑ l SELF MONITORING ❑ T. SELFMONITORING GRAVITY FLOW GRAVITY FLOW(Cheek as Mal apply): ❑ 9. BIENNIAL INTEGRITY TEST(0.1 GPH) ❑ 8. DAILY NSUAL MONITORING ❑ % BIENNIAL INTEGRITY TEST 10.1 GPH) SECONDARILY CONTAINED PIPING SECONDARILY CONTAINED PIPING PRESSURIZED PIPING(Check all that apply): PRESSURIZED PIPING(Cheek ad that appy): M CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL AND 10.CONTINUOUS TURBINE SUMP SENSOR HATH AUDIBLE AND VISUAL ALARMS AND(eHerk one) ❑ 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 ❑ e- NO AUTO PUMP SHUT OFF ❑ e. NO AUTO PUMP SHUT OFF ❑ 11. AUTOMATIC UNE LEAK DETECTOR(3.0 GPH TEST)HATH FLOW SHUT OFF OR ❑ 11. AUTOMATC LEAK OETECTOR RESTRICTION ❑ 12.ANNUAL INTEGRITY TEST(0.1 GPH) ❑ 12. ANNUAL INTEGRITY TEST 10.1 GPH) SUCTON/GRAVITY SYSTEM: SUCTIONIGRAVITY SYSTEM: ❑ 13. CONTINUOUS SUMP SENSOR.AUDIBLE AND VISUAL ALARMS ❑ 13. CONTINUOUS SUMP SENSOR.AUDIBLE AND VISUAL ALARMS EMERGENCY GENERATORS ONLY(Check al that appy) EMERGENCY GENERATORS ONLY(ChactW that apply) ❑ 14. CONTINUOUS SUMP SENSOR WTHOUT AUTO PUMP SHUT OFF+AUDIBLE AND ❑ 16. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF.AUDIBLE AND VISUAL VISUALALARMS ALARMS ❑ 15. AUTOMATIC UNE LEAK DETECTOR(3.0 GPH TEST)WITHOUT FLOW SHUT OFF OR ❑ 15. AUTOMATIC UNE LEAK DETECTOR(10 GPH TEST) RESTRICTION ❑ 18.ANNUAL INTEGRITY TEST(0.1 GPH) ❑ i6. 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 ❑ d. DAILYVISUALCHECK DATE INSTALLED ❑ 2. CONTINUOUS DISPENSER PAN SENSOR+AUDIBLEANOVISUALALARMS ❑ S. TRENCH LINER/MONITORING ❑ 3. CONTINUOUS DISPENSER PAN SENSOR MATH AUTO SHUT OFF FOR DISPENSER+AUDIBLEAND VISUALALARMS ❑ B. NONE UL OWNER/OPERATOR SIGNATURE I unity mat the information proaded haven is We and accuvte to me best of my kncraw'. SIGNATURE OF OWNER/OPERATOR DATE NAME OF CANNERIOPERATOR(pnn0 TITLE OF OWNEWOPERATOR Palms Number(F."peal uae poly) Permit Age sma d(Farlosel pee eMy Permit E ppaaoo Dale iForlacal use Dory) 1L �1j2149 CUPAFORM(4/99) Formerly SWRCB Form B