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UNIFIED PROGRAM CONSOLIDATED FORM TANKS UNDERGROUND STORAGE TANKS--TANK PAGE 2 VL PIPING CONSTRUCTION(cher all thatapply) Pegr Z of UNDERGROUND PIPING ABOVEGROUND PIPING SYSTEM TYPE ®1.PRESSURE' ❑2,SUCTION ❑3.GRAVITY 458 ❑1.PRESSURE ❑2. STICTION ❑3.GRAVITY 4u9 CONSTRUCTION ❑1.SING I3i WAIL ❑3.LINED TRENCH ❑99.OTHI.R 460 ❑1.SINGLE WALL ❑95.UNKNOWN 462 MANUFACTURER ®2.DOUBLE WALL, ❑95.UNKNOWN ❑2.DOUBLE WALL ❑99.OTHF,R MANUFACTURER Smith Fiber ass 461 MANUFACTURER 463 ❑1.HARE STEEL ®6.PRP COMPATIBLE WIWI/. METHANOL ❑1.HARE STEEL ❑6.FRY COMPA771311,WI10(r/.METHANOL ❑2.STAINLESS STEEL ❑7.GALVANIZED STEEL ❑Unknown ❑2. STAINLESS STEEL 0 7.GALVANIZED STEEL [13.PLASTIC COMPATIBLE W/CONTENTS ❑99. Other ❑3. PLASTIC COMPATIBLE W/CONTENTS ❑R.FLEXIBLE(HDPE) [199. OTHER ❑4.FIBERGLASS [18.FLEXIBLE(IIDPE) ❑4. FIBERGLASS ❑9.CATHODIC PROTECTION ❑5.STEEL WICOATING L]9.CATHODIC PROTECTION 464 ❑5. STEEL W/COATING ❑95.UNKNOWN 465 VII.PIPING LEAK DETECTION(Cheek all that apply)(A dcacri tion of the monitoring ro shall be submitted to the local agency) UNDERGROUND PIPING ABOVEGROUND PIPING SINGLE WALL PIPING 456 SINGLE WALL PIPING 467 PRESSURIZED PIPING(Check all that apply): PRESSURIZED PIPING(ehcok all that apply) 1.ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP SHUT ❑I. EI.I CTRONIC LINE LEAK DETECTOR 3.0 GPH TFST WITH AUTO PUMP OFF FOR LEAK-SYSTEM FAILURE,AND SYSTEM DISCONNECTION+ SHUTOFF 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(0.1 GPH) ❑3.ANNUAL INTEGRITY TEST(0.I GPH) E34. DAILY VISUAL CHECK CONVENTIONAL STICTION SYSTEMS CONVENTIONAL SUCTION SYSTEMS(Check all that apply) ❑5.DAILY VISUAL MONITORING OF PUMPING SYSTEM+TRIENNIAL PIPING INTEGRITY TEST(0.1 GPH) ❑S. DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM SAFE SUCTION SYSTEMS(NO VALUES IN BELOW GROUNDPIPING): ❑6. TRIENNIAL INTEGRITY TEST(0.1 GPH) ❑7.SELFMONITORING SAFE SUCTION SYSTEMS(NO VALVES IN BELLOW GROUND PIPING): GRAVITY FLOW ❑7. SELF MONITORING [19.BIENNIAL INTEGRITY TIS I(0.1 GPH) GRAVITY FLAW(Check all that apply). 0 8. DAILY VISUAL MONITORING ❑9. BIENNIAL INTEGRITY TEST(0.i(3PH) SECONDARILY CONTAINED PIPING SECONDARILY CONTAINED PIPING PRESSURIZED PIPING(Cheek all that apply), PRESSURIZED PIPING(Check s11 that apply). 10. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL 10. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL ALARMS AND(Check ane) ALARMS AND(Check one) []a. AUTO PUMP sB T 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 ❑It AUTO PUMP SHIN OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM DISCONNECTION DISCONNECTION ❑]c. NO AUTO PUMP SHUT OFF El NO AUTO PUMP SHUT OFF 11. AUTOMATIC LINE LEAK DETECTOR(3.0 OPH TEST)WITH FLAW SHUT OFF OR RESTRICTION ❑11. AUTOMATIC LEAK DETECTOR ❑12. ANNUAL INTEGRITY TEST(0.1 GPH) ❑12. ANNUAL INTEGRITY TEST(0.1 GPH) SUCTIONIGRAVITY 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) EMERGENCY GENERATORS ONLY(cheakan that apply) ❑14. CONTINUOUS SUMP SENSOR W1TIiOUT AUTO PUMP SHUT OFF ❑14. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF' AUDIBLE AND VISUAL ALARMS AUDIBLE AND VISUAL ALARMS ❑ S. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)WITH FLOW ❑15. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST) SHUT OFF OR RESTRICTION ❑16.ANNUAL INTEGRITY TEST(0.1 GPH) [:116.ANNUAL INTEGRITY TEST(0.1 GPH) ❑17. DAILY VISUAL.CHECK ❑17. DAILY VISUAL CHECK VIII.DISPENSER CONTA.INNIENT DISPENSER CONTAINMENT ❑I.FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE ❑4.DAILY VISUAL CHECK DATE INSTAL LED 468 ❑2.CONTINUOUS DISPENSER PAN SENSOR+AUDIBLE AND VISUAL ALARMS ❑5.TRENCH LINER/MONITORING 2003 ®3.CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR ❑6 NONE 469 DISPENSER+AUDIBLE AND VISUAL ALARMS IX.OWNERIOPERATOR SIGNATURE I certify that the infcrmati nvidedlhqrcinjs true and aecurate to the best of ry knowledge. SIGNof DATF, ala NAME OF OWNER/OPRATOR(Print) 471 TITLE OFOTNERA4PERATOR 472 Ste hen I:]udt President. Permit Number(For local use only) 473 Permit Approved(For local use only) 474 Permit Expiration Datc(Far local use only) 475 UPCF(12199 revised) 12 Formerly SWRCB Form B