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UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANKS- TANK PAGE 2 TANKS VI.PIPING CQIYS'ITtUCT1ON(Check all thm ly) I)NDERGROUND PIPING Pale or 2 SYSTEM TYPE 1.PRISSUREAI3OvECYROUNI3 PIPIM ❑2.SUCTION ❑3.GRAVITY 458 ❑1.PRI;SSLJRE ❑2. SUCTION CUNSTI2ilCT10N ElI.SINGLE WALLEl3.].INF,D TRENCII El 3.GRAVITY 459 ❑99.OTHER 46,0 El 1.SINGLE WALL 1195.UNKNOWN 462 MANUFACTURER ®2.DOUBLE WALL ❑95.UNKNOWN ❑2.DOUBLY..'WAI.I. 13 99.OTI{ER MANUFACTURER Smith Fiber IaSS 461 MANUFACTURER ❑I.BARE STEEL Z 6.FRP COMPATIBLE w/I00°h MTYHANOI. ❑I.BARE STEIN, W463 ❑2.STAINLESS STEEL 116.FRP COMPATIBLE t1WiMETHANOL ❑7.GALVANIZED STEEL ❑unknown C1 2. sT'AINLESs STEEL [:17.3.PLASTIC GALVANIZED STEEL PLASTIC COMPATIBLE W/CONT'ENT'S ❑99. Other [13. PLASTIC COMPATIBLE W/CONTENTS ❑4.FIBERGLASS ❑9.FLE)3BLE(HDPE) G s.CATHODFLE>aBLIC (HDPE) 1199. gTl{ER ❑4. FIBERGLASS ❑9,CAT]{ODIC PROT'F.CFION ❑5.STEEL W/COATING ❑9,CATHODIC PROTECTION 464 ❑5. STEEL W/COATING ❑45.UNKNOWN 465 VII.PIPING LEAK DETECTION(Check ell that a I)(A 4eamptjon arae monitorin program shall be submitted to the locale Agency) UNDERGROUND PIPING SINGLE WALL PIPINGABOVEGROUND PIPING°M SINGLE WALL PIPING PRESSURIZED PIPING(Cheek a]]that apply): PRESSURIZED PIPING(check au that apply) 467 ❑1.ELECTRONIC LINE LEAK DE'T'ECTOR 3.0 GPB TEST WITH AUTO PUMP SHUT OFF FOR LEAK,SYSTEM FAILURE,AND SYSTEM DISCONNECTION+ ❑I' ELECTRONIC LINE LEAK DETECTOR 30 GPH TEST WITH AUTO PUMP AUDIBLE AND VISUAL ALARMS, SHUT OFF FOR LEAK,SYSTEM FAILURE,AND SYSTEM DISCONNECTION+ ❑2.MONTHLY 0„2 GPH TEST AUDIBLE AND VISUAL ALARMS. Cl 2. MONTHLY 0.2 GPH TEST El3.ANNUAL INTEGRIT Y'rEST(O.1GPH) ❑3.ANNUAL INTEGRITY TEST(0.IGPH) El 4. DAILY VISUAL CHECK CONVENTIONAL SUCTION SYSTEMS CONVENTIONAL SUCTION SYSTEMS(Cheat;all that apply) ❑5.DAILY VISUAL MONITORING OF PUMPING SYSTEM+TRIENNIAL PIPING INTEGRITY TESTC0.1 GPH) ❑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 GRAVITY FLOW SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): 117. SELF MONITORCNG ❑9,BIENNIAL INTEGRITY TEST(0.1 GPH) GRAVITY FLOW(Che&all that apply): ❑S, DAILY VISUAL MONITORING SECONDARILY CONTAINED pIFING El9. BIENNIAL INTEGRITY TEST(0.1 GPH) SECONDARILY CONTAINED PIPING PRESSURIZED PIPING(Cheasin drat apply): PRESSURIZED PIPING(cheer all that apply), 1 O. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL ALARMS AND(Cheek out) 10. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL Ela- AUTO PUMP SHUT OFF WHEN A LEAK OCCURS ALARMS AND(Check one) 0 b. AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM Ll a AUTO PUMP SHUT OFF WHEN A LEAK OCCURS DISCONNECTION ❑b AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM ❑e. NO AUTO PUMP SHUT OFF DISCONNECTION ®1 I. AUTOMATIC LINE LEAK DETECTOR(3A GPH TES WITIi FLOW SHUT ❑c NO AUTO PUMP SHUT OFF OFF OR RESTRICTION 1111- AUTOMATIC LEAK DETECTOR ❑12. ANNUAL INTEGRITY TEST(0.1 GPH) ❑12. ANNUAL INTEGRITY TEST(O.f GPH) SUCTION/GRAVITY SYSTEM SUCTION/GRAVITY SYSTEM ❑13. CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS ❑13. CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS EMERGENCY GENERATORS ONLY(Check all that apply) ❑14. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF+ EMERGENCY GENERATORS ONLY(Check all that apply) AUDIBLE AND VISUAL ALARMS ❑I4. CONTINUOUS Sl-IMP SENSOR OUT AUTO PUMP SI{iJT OFF; ❑15. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)WITHOUT FLOW AUDIBLE AND VISUAL ALARMS SHUT OFF OR RESTRICTION 1:115. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST) El 16.ANNUAL INTEGRITY TEST(0.1 OPH) ❑16.ANNUAL INTEGRrrY[EST(0.1 GPH) F-1 17. DAILY VISUAL CHECK ❑17. DAILY VISUAL CHECK VIII.DISPENSER CONTAINMEIQT DISPENSER CONTAINMENT []1.ITAAT MECHANISM THAT SIiUTS OFF SHEAR VALVE DATE INSTALLED 468 ❑4.DAILY VISUAL CHECK ❑2.CONTINUOUS DISPENSER PAN SENSOR+AUDIBLE AND VISUAL ALARMS l 1 5.TRENCH LINER/MONITORING 2003 ED 3.CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR DISPENSER+AUDIBLE AND VISUAL ALARMS ❑6.NONE 469 IX.OWNER/OPERATOR SIGNATURE I certify that iLl ! "id herein is true and aeeumte to the best ormy knowledge. SIGN F WNE OR DATE (-7 t -5 OZ 70 4 NAME O WNER/gT'RATOR(prim) 471 TITLE OF 0 PECRATOR Stephen Kludt 47� President Panni[Number(For local use ors1Y) 473 Permit Approved(For local use only) 474 Permit Expiration Date{For loos,/use Doty) 47:5 [JPCF(12/99 revised) 12 Formerly SWRCB Forfar B