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u NIFIED PROGRAM CONSOLIDATED FORM TANKS UNDERGROUND STORAGE TANKS - TANK PAGE 2 VI.PIPING CONSTRUCmON(Checkoff that appy) UNDERGROUND PIPING ABOVEGROUND PIPING SYSTEM TYPE 1. PRESSURE ❑ 2. SUCTION ❑ 3. GRAVITY ❑ 1. PRESSURE ❑ 2. SUCTION ❑ 3. GRAVITY CONSTRUCTION/ ❑ 1. SINGLE WALL ❑ 3. LINED TRENCH ❑99. OTHER ❑ 1, SINGLE WALL 1195. UNKNOWN MANUFACTURER '�j 2 DOUBLE WALL ❑95. UNKNOWM ❑ 2. DOUBLE WALL ❑N. OTHER MANUFACTURER MANUFACTURER ❑ 1.BARE STEEL ❑ e. FRPCOMPATISLEW/100%METHANOL, ❑ 1. BARE STEEL ❑ e. FRP COMPATIBLE W/100%METHANOL MATERIALS AND ❑ 2, STAINLESS STEEL ❑ T. GALVANIZED STEEL ❑ 2. STAVNLESS STEEL ❑ T. GALVANIZED STEEL CORROSION PROTECTION ❑ 3. PLASTIC COMPATIBLE W/TH CONTENTS 1195. UNKNOWN ❑ 3. PLASTIC COMPATIBLE WITH CONTENTS ❑ a. FLEXIBLE(HDPE) ❑99. OTHER '�k4. FIBERGLASS ❑ 8. FLEXISLE(HDPE) ❑99.OTHER 114. FIBERGLASS 119. CATHODIC PROTECTION ❑ 5. STEEL W/COATING 119. CATHODIC PROTECTION ❑ 5. STEEL WI COATING El 95 UNKNOWN VIL PIPING LEAK DETECTION(Check agtheNpplyl UNDERGROUND PIPING ABOVEGROUND PIPING SINGLE WALL PIPING SINGLE WALL PIPING PRESSURIZED PIPING(Check al that apply): PRESSURIZED PIPING(Check as that appy): ❑ 1. ELECTRONIC LINE LEAK DETECTOR 3.0 GPM TEST WITH AUTO PUMP SHUT OFF FOR ❑ 1. ELECTRONIC LINE LEAK DETECTOR 3.0 GPM TEST WITH AUTO PUMP SHUT OFF FOR LEAK, LEAK,SYSTEM FAILURE,AND SYSTEM DISCONNECTION I AUDIBLE AND VISUAL SYSTEM FAILURE,AND SYSTEM DISCONNECTION•AUDIBLE AND VISUAL ALARMS ALARMS ❑ EST 2. MONTHLY 02GPH TEST ❑ Z ANNUALINTEG INTEGRITY TES ❑ 3. ANNVALINTEGRITY TEST(0.1 GPM) ❑ 3. ANNUAL INTEGRITY TEST(0.1 GPM) ❑ 4. DAILY VISUAL CHECK CONVENTIONAL SUCTION SYSTEMS'. CONVENTIONAL SUCTION SYSTEMS(Check all that apply): ❑ 5. DAILY VISUAL MONITORING OF PUMPING SYSTEM a TRIENNIAL PIPING INTEGRITY ❑ S. DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM TEST(0.1 GPM) ❑ B. TRIENNIAL INTEGRITY TEST(0.1 GPM) SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): ❑ ]. SELF MONITORING ❑ T. SELF MONITORING GRAVITY FLOW GRAVITY FLOW(Check all that appy): ❑ 9. BIENNIAL INTEGRITY TEST(0.1 GPM) ❑ a. DAILY VISUAL MONITORING ❑ 9. BIENNIAL INTEGRITY TEST(0.1 GPM) SECONDARILY CONTAINED PIPING SECONDARILY CONTAINED PIPING PRESSURIZED PIPING(Chock all that apply): PRESSURIZED PIPING(Check all that apply): 10. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL ALARMS AND Check Dnp 10.CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL ALARMS AND(crack one) a. AUTO PUMP SHUT OFF MEN A LEAK OCCURS ❑ a. AUTO PUMP SMUT OFF WHEN A LEAK OCCURS h. AUTO PUMP SHUTOFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM ❑ h_ AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM DISCONNECTION DISCONNECTION ❑ c. NO AUTO PUMP SHUTOFF ❑ c. NOAUTOPUMPSMUTOFF 11. AUTOMATIC LINE LEAK DETECTOR(3.0 GPM TEST)WITH FLOW SMUT OFF OR ❑ 11, AUTOMATIC LEAK DETECTOR RESTRICTION ❑ 12. ANNUAL INTEGRITY TEST(0.1 GPM) ❑ 12. ANNUAL INTEGRITY TEST(0.1 GPM) SUCTION/GRAVITY SYSTEM: SUCTIOWGRAVITY SYSTEM: ❑ 13. CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS ❑ 13. CONTINUOUS SUMP SENSOR t AUDIBLE AND VISUAL ALARMS EMERGENCY GENERATORS ONLY(Check all that appy) EMERGENCY GENERATORS ONLY(Check as that apply) ❑ 14.CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF.AUDIBLE AND ❑ 14. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF+AUDIBLE AND VISUAL VISUALALARMS ALARMS ❑ 15.AUTOMATIC LINE LEAK DETECTOR(3.0 GPM TEST)WITHOUT FLOW SHUT OFF OR ❑ 16. AUTOMATIC UNE LEAK DETECTOR(3.0 GPM TEST) RESTRICTION ❑ 16.ANNUAL INTEGRITY TEST(0 1 GPM) ❑ 16. ANNUAL INTEGRITYTEST(0.1 GPM) ❑ 17. DAILYVISUALCHECK ❑ 1T. DAILY VISUAL CHECK VIII.DISPENSER CONTAINMENT DISPENSER CONTAINMENT ❑ 1. FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE ❑ 4. DAILY VISUAL CHECK DATE INSTALLED ❑ 2. CONTINUOUS DISPENSER PAN SENSOR-AUDIBLE AND VISUAL ALARMS ❑ S. TRENCH LINER/MONITORING I/aMuy&VI//ws 3. CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR DISPENSER i AUDIBLE AND VISUAL ALARMS ❑ 6. NONE IX.OWNERIOPERATOR SIGNATURE I century Mat Me infontaeon provided herein is to rad aCturale to Ma pool of my knoMedtie. SIGNAGYqEO i2 EMPTO i6e DATE D NAME OFMOPERATOR(,P"4 L. n TITLED PERATOR Paonit Ntsnin r(For local am only) Pennil Approve l(For local use any) Pemtii Expiration Data(Forbcal a»cW CUPAFORM(4/99) • Formerly SWRCB Form B