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UNIFIED PROGRAM CONSOLIDATED FORM <br /> a TANKS <br /> UNDERGROUND STORAGE TANKS -TANK PAGE 2 <br /> VI.PIPING CONSTRUCTION Checkall Natapply) <br /> page <br /> UNDERGROUND PIPING ABOVEGROUND PIPING <br /> SYSTEM TYPE I.PRESSURE O 2.SUCTION O 3.GRAVITY 458 O 1,PRESSURE ❑2. SUCTION O 3.GRAVITY 459 <br /> CONSTRUCTION .SINGLE WALL O 3.LINED TRENCH O 0 O 99.OTHER 461.SINGLE WALL O 95.UNKNOWN 461 <br /> MANUFAC IJRER(22.DOUBLE WALL O 95.UNKNOWN O 2.DOUBLE WALL O 99.OTHER <br /> MANUFACTURER 461 MANUFACTURER 463 <br /> ❑1.BARE STEEL [16.FRP COMPATIBLE W/10096 METHANOL OL BARE STEEL O 6.FRP COMPATIBLE W/100%METHANOL <br /> O 2,STAINLESS STEEL O 7.GALVANIZED STEEL O Unknown O 2. STAINLESS STEEL O 7.GALVANIZED STEEL <br /> [13.PLASTIC COMPATIBLE W/CONTENTS O 99. Other [13. PLASTIC COMPATIBLE W/CONTENTS O S.FLEXIBLE(HDPE) [199. OTHER <br /> 4.FIBERGLASS O 8.FLEXIBLE(HDPE) O 4. FIBERGLASS O 9.CATHODIC PROTECTION <br /> ❑5.STEEL W/COATING [19.CATHODIC PROTECTION 464 O 5. STEEL W/COATING [195.UNKNOWN 465 <br /> VII.PIPING LEAK DETECTION(Chcckall Nm I AEesmioor of Ne mooisorm shall be submitted to she 1001 nc. <br /> UNDERGROUND PIPING ABOVEGROUND PIPING <br /> SINGLE WALL PIPING 466 SINGLE WALL PIPING 467 <br /> PRESSURIZED PIPING(Check all that apply): PRESSURIZED PIPING(Check all that apply): <br /> ❑1.ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP SHUT [11. ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP <br /> OFF FOR LEAK,SYSTEM FAILURE,AND SYSTEM DISCONNECTION+ SHUT OFF FOR LEAK,SYSTEM FAILURE,AND SYSTEM DISCONNECTION+ <br /> AUDIBLE AND VISUAL ALARMS. AUDIBLE AND VISUAL ALARMS. <br /> O 2.MONTHLY 0.2 GPH TEST [12. MONTHLY 0.2 GPH TEST <br /> O 3.ANNUAL INTEGRITY TEST(O.IGPH) O 3.ANNUAL INTEGRITY TEST(O.IGPH) <br /> [14. DAILY VISUAL CHECK <br /> CONVENTIONAL SUCTION SYSTEMS CONVENTIONAL SUCTION SYSTEMS(Check dl that apply) <br /> O 5.DAILY VISUAL MONITORING OF PUMPING SYSTEM+TRIENNIAL PIPING [15. DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM <br /> INTEGRITY TEST(0.1 GPH) <br /> SAFE SUCTION SYSTEMS(NO VALUES IN BELOW GROUNDPIPING): O 6. TRIENNIAL INTEGRITY TEST(0.1 GPH) <br /> O 7.SELF MONITORING SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): <br /> GRAVITY FLOW 07. SELF MONITORING <br /> [19.BIENNIAL INTEGRITY TEST(0.1 GPH) GRAVITY FLOW(Check all Nat apply): <br /> [18. DAILY VISUAL MONITORING <br /> O 9. BIENNIAL INTEGRITY TEST(0.1 GPH) <br /> SECONDARILY CONTAINED PIPING SECONDARILY CONTAINED PIPING <br /> PRESSURIZED PIPING(Check all that apply): PRESSURIZED PIPING(Check all that apply): <br /> 10. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL 10. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL <br /> AARMS AND(Check one) ALARMS AND(Check one) <br /> s. AUTO PUMP SHUT OFF WHEN A LEAK OCCURS O e AUTO PUMP SHUT OFF WHEN A LEAK OCCURS <br /> O It. AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM O b AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM <br /> DISCONNECTION DISCONNECTION <br /> �[ Oc. NO AUTO PUMP SHUT OFF Op NO AUTO PUMP SHUT OFF <br /> f61 11. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)WITH FLOW SHUT O H. AUTOMATIC LEAK DETECTOR <br /> I` OFF OR RESTRICTION <br /> ❑12. ANNUAL INTEGRITY TEST(0.1 GPH) [112. ANNUAL INTEGRITY TEST(0.1 GPH) <br /> SUCTIOMORAVITY SYSTEM SUCTIOWGRAVITY SYSTEM <br /> 013. CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS 013. CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS <br /> EMERGENCY GENERATORS ONLY(Check all that apply) EMERGENCY GENERATORS ONLY(Check all that apply) <br /> O 14. CONTINUOUS SUMP SENSOR WITH 011T AUTO PUMP SHUT OFF• O 14. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF <br /> AUDIBLE AND VISUAL ALARMS AUDIBLE AND VISUAL ALARMS <br /> ❑ 15. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)WITH FLOW [115. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST) <br /> SHUT OFF OR RESTRICTION <br /> O <br /> 16.ANNUAL INTEGRITY TEST(0.1 GPH) [116.ANNUAL INTEGRITY TEST(0.1 GPH) <br /> ❑17. DAILY VISUAL CHECK [117. DAILY VISUAL CHECK <br /> VIII.DISPENSER CONTAINMENT <br /> DISPENSER CONTAINMENT O 1.FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE [14.DAILY VISUAL CHECK <br /> DATE TALLED 468 2.CONTINUOUS DISPENSER PAN SENSOR+AUDIBLE AND VISUAL ALARMS O 5.TRENCH LINER/MONITORING <br /> �- 3.CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR O 6,NONE 469 <br /> DISPENSER+AUDIBLE AND VISUAL ALARMS <br /> IX.OWNERIOPERATOR SIGNATURE <br /> Icon Nes Ne is inion provided herein is nue and accurate to the ben ofmy knowledge. <br /> SIGNATU OF E PE DATE470 <br /> INA 471 IJJTLE OF OWNER/OPE OR 472 <br /> t?regi <br /> Permit Number(For local use only) 473 Permit Appmvcd(For local use only) 474 Permit Expiration Dole(For local use only) 475 <br /> UPCF(12/99 revised) 12 Formerly SWRCB Form B <br />