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UNIFIED PROGRAM CONSOLIDATED FORM TANKS UNDERGROUND STORAGE TANKS - TANK PAGE 2 W.PIPING CONSTRUCTION(ChaFkadJhatappty) UNDERGROUND PIPING ABOVEGROUND PIPING SYSTEM TYPE PRESSURE ❑ 2, SUCTION ❑ 3. GRAVITY ❑ 1. PRESSURE ❑ 2. SUCTION ❑ 3. GRAVITY CONWRUCTIONI ❑ 1 SINGLE WALL ❑ 3. LINEDTRENCH ❑99. OTHER ❑ 1. SINGLE WALL 1:195. UNKNOWN MANUFACTURER DOUBLE WALL ❑95. UNKNOWN ❑ 2. DOUBLE WALL ❑W. OTHER MANUFACTURER MANUFACTURER - ❑ 1.BARE STEEL ❑ B. FRP COMPATIBLE W/100%METHANOL ❑ 1. BARE STEEL ❑ B. FRP COMPATIBLE W/100%METHANOL MATERIALS AND ❑ 2.STAINLESS STEEL 11 T. GALVANIZED STEEL ❑ 2. STAINLESS STEEL 11 T.GALVANIZED STEEL - CORROSION PROTECTION ❑ . PLASTIC COMPATIBLE MATH CONTENTS 119& UNKNOWN 113. PLASTIC COMPATIBLE WITH CONTENTS ❑ B. FLEXIBLE(HOPE) - El 99. OTHER 4. FIBERGLASS ❑ 8. FLEXISLEMDPE) 1199. OTHER ❑ 4. FIBERGLASS ❑ 9. CATHODIC PROTECTION ❑ 5. STEELWICOATING ❑ 9. CATHODIC PROTECTION ❑ 5. STEELWICOATING 1195. UNKNOWN VII.PIPING LEAK DETECTION(Check adihat appy) UNDERGROUND PIPING ABOVEGROUND PIPING SINGLE WALL PIPING PRESSURIZED PIPING(DhNk eN that appyJ: PRESSURIZED PIPING(Check ep that appy):SINGLE WALL PIPING ❑ 1. ELECTRONIC LINE LEAK DETECTOR SO GPM TEST WITH AUTO PUMP SHUT OFF FOR ❑ 1. ELECTRONIC UNE LEAK DETECTOR 3.0 GPM TEST WITH AUTO PUMP SHUT OFF FOR LEAK, LEAK,SYSTEM FAILURE.AND SYSTEM DISCONNECTION r AUDIBLE AND VISUAL SYSTEM FAILURE,AND SYSTEM DISCONNECTION:AUDIBLE AND VISUAL ALARMS ALARMS 132. MONTHLY 0.2 GPMST ST 11 3ANNUAL INTEGRITY 11 2. MONTHLYGP133. ANNUAL INTEGRITY TEST(0.1 GPM) . Y TTEST(0.1 GPM)ES ❑ 4. DAILY VISUAL CHECK CONVENTIONAL SUCTION SYSTEMS: CONVENTIONAL SUCTION SYSTEMS(Check ell that appy): ❑ S. DAILY VISUAL MONITORING OF PUMPING SYSTEM-TRIENNIAL PIPING INTEGRITY ❑ S. DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM TEST(0.1 GPM) ❑ B. TRIENNIAL INTEGRITY TEST IDA GPM) SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING)' ❑ T. SELFMONITORING ❑ i. SELFMONITORING GRAVITY FLOW: - GRAVITY FLOW(Checked that apply): ❑ 9. BIENNIAL INTEGRITY TEST(0.1 GPM) ❑ 8. DAILY VISUAL MONITORING ❑ 9. BIENNIAL INTEGRITY TEST(0.1 GPM) SECONDARILY CONTAINED PIPING SECONDARILY CONTAINED PIPING PRESSURIZED PIPING(Check alllhaf apply): PRESSURIZED PIPING(Check ad that SECO SECO 10. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL ALARMS AND (Check one) 10.CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL ALARMS AND(rAeck one) ❑ a. AUTO PUMP SHUT OFF MEN A LEAK OCCURS ❑ a.AUTO PUMP SHUT OFF WHEN A LEAK OCCURS \ ❑ 0 AUTO PUMP SMUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM ❑ AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM DISCONNECTION NO AUTO PUMP SHUT OFF ❑ C. NOAUTO PUMP SHUT OFF DISCONNECTION 0. ❑ t. AX MATIC LINE LEAK DETECTOR(3.0 GPM TEST)WITH FLOW SHUT OFF OR RESTRICTION 1111. AUTOMATIC LEAK DETECTOR ❑ 12.ANNUAL INTEGRITY TEST KA GPM) ❑ 12. ANNUAL INTEGRITY TEST(0.1 GPM) SUCTIOWGRAVITY SYSTEM: SUCTION/GRAVITY SYSTEM: ❑ 13. CONTINUOUS SUMP SENSOR-AUDIBLE AND VISUAL ALARMS ❑ 13. CONTINUOUS SUMP SENSOR v AUDIBLE AND VISUAL ALARMS EMERGENCY GENERATORS ONLY(Check aft hurt appy) EMERGENCY GENERATORS ONLY(Check ad that spplyt ❑ 14.CONTINUOUS SUMP SENSOR`MTHOUT AUTO PUMP SHUT OFF-AUDIBLE AND ❑ VISUALALARMS 14, CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF•AUDIBLE AND VISUAL ALARMS ❑ 15.AUTOMATIC LINE LEAKeE C ORyRL0,GPH TEST)WTHOUT FLOW SHUT OFF OR ❑ 15. AUTOMATIC LINE LEAK DETECTOR(3.0 GPM TEST) RESTRICTION ❑ 16.ANNUAL INTEGRITY TEST(0.1 GPM) ❑ 16. ANNUAL INTEGRITY TEST(0.1 GPM) ❑ 17. DAILY VISUAL CHECK L] 1T. GAILY VISUALCHECK VIII.DISPENSER CONTAINMENT DISPENSER CONTAINMENT FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE ❑4. DAILY VISUAL CHECK DAT INST D� 132. CONTINUOUS DISPENSER PAN SENSOR a AUDIBLE AND VISUAL ALARMS 115. TRENCH LINER/MONITORING C] 3. CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR DISPENSER.AUDIBLE AND VISUAL ALARMS ❑ C NONE IX.OWNERIOPERATOR SIGNATURE I mrnly Mat Ihe'MfOrm liOn pmNaee herein is hue.ho aorurete to Ma WSI of my knowletl9a. SIGNATURE OF OWNER,eK,,,OR DATE NAME OF OWMEWOPERATOR(pnot) TITLE OF OVMEILOPERATOR Permit Number(Forlooal use Dory) Permit Appmvea(Fprlocal use oMy) Permit Eviration Data(Forlocal use only) CUPAFORM(4/99) • • Formerly SWRCB Form B