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F UNIFIED PROGRAM CONSOLIDATED FORM TANKS UNDERGROUND STORAGE TANKS -TANK PAGE 2 VI,PIPING CONSTRUCTION Check all that app! Page_of- UNDERGROUND PIPING ABOVEGROUND PIPING SYSTEM TYPE N 1.PRESSURE ❑2.SUCTION ❑3.GRAVITY 459 ❑I,PRESSURE ❑2. SUCTION ❑3.GRAVITY 459 CONSTRUCTION [11.SINGLE WALL ❑3.LINED TRENCH ❑99 .OTHER 460 ❑1.SINGLE WALL ❑95,UNKNOWN 462 MANUFACTURER ®2.DOUBLE WALE [195.UNKNOWN [12.DOUBLE WALL ❑99.OTHER MANUFACTURER 461 MANUFACTURER 469 ❑ I.BARE STEEL ❑6.FRP COMPATIBLE w/i00% mErHANOL ❑I.BARE STEEL ❑6.FRP COMPATIBLE W/100%METHANOL [12.STAINLESS STEEL [17.GALVANIZED STEEL ❑Unknown ❑2. STAINLESS STEEL ❑7.GALVANIZED STEEL ❑3.PLASTIC COMPATIBLE W1 CONTENTS ❑99. Other ❑3. PLASTIC COMPATIBLE W/CONTENTS ❑8.FLEXIBLE(HDPE) [199. OTHER ®4.FIBERGLASS ❑8.FLEXIBLE(HDPE) ❑4. FIBERGLASS 9.CATHODIC PROTECTION EJ5.STEEL W/COATING El9.CATHODIC PROTECTION 464 ❑ ❑5. STEEL W/COATING ❑95.UNKNOWN 465 VII.PIPING LEAK DETECTION(Check all that apply) A dcseri tion ofthe monitoring progrant shall be submitted to the local agency.) UNDERGROUND PIPING ABOVEGROUND PIPING SINGLE WALL PIPING 466 SINGLE WALL PIPING 467 PRESSURIZED PIPING(Check all that apply): PRESSURIZED PIPING(Check all that apply): I.ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP SHUT ❑I. ELECTRONIC LINE LEAK DETECTOR 3.0 GPI{TEST WITH AUTO PUMP OFF FOR LEAK,SYSTEM FAILURE,AND SYSTEM DISCONNECTION+ SHUT OFF 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 GPI I TEST ❑3.ANNUAL.INTEGRITY TEST(0.1 GPH) ❑3.ANNUAL INTEGRITY TEST(0.1 GPH) ❑4. DAILY VISUAL CHECK CONVENTIONAL SUCTION SYSTEMS CONVENTIONAL SUCTION SYSTEMS(Check all that apply) ❑5.DAILY VISUAL MONITORING OF PUMPING SYSTEM+TRIENNIAL PIPING INTEGRITY TEST(0.1 GPH) [35. DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM SAFE SUCTION SYSTEMS(NO VALUES IN BELOW GROUNDPIPING): ❑6. TRIENNIAL INTEGRITY TEST(0.l GPH) ❑7.SELF MONITORING SAFE SUCTION SYSTEMS(NO VALVES 1N BELOW GROUND PIPING): GRAVITY FLOW ❑7. SELF MONITORING ❑9.BIENNIAL INTEGRITY TEST(0,1 GPH) GRAVITY FLOW(Check all that apply); S. DAILY VISUAL MONITORING ❑9. BIENNIAL INTEGRITY TEST(0.l GPH) SECONDARILY CONTAINED PIPING SECONDARILY CONTAINED PIPING PRESSURIZED PIPING(Check all that apply): PRESSURIZED PIPING(Chcck all that apply): 10, CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL 10. CONTINUOUS TURBINE SUMP SENSOR WITI I AUDIBLE AND VISUAL ALARMS AND(Check one) ALARMS AND(Check one) ®a. AUTO PUMP SHUT 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 0 b AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM DISCONNECTION DISCONNECTION ❑c. NO AUTO PUMP SHUT OFF ❑c NO AUTO PUMP SHUT OFF e.] 11. AUTOMATIC LINE LEAK DETECTOR(3,0 GPH TEST)) ITH FLOW SHUT OFF OR RESTRICTION ®11. AUTOMATIC LEAK DETECTOR ®12. ANNUAL INTEGRITY TEST(0.1 GPH) ®12. ANNUAL INTEGRITY TEST(0.1 GPH) SUCTION/GRAVITY SYSTEM SUC]'ION/GRAVITY SYSTEM {�] 13. CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS U 13. CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL.ALARMS EMERGENCY GENERATORS ONLY(Chcck all that apply) EMERGENCY GENERATORS ONLY(Check all that apply) ❑14. CONTINUOUS SUMP SENSOR WIT]IOU T AUTO PUMP SHUT OFF* ❑14. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF AUDIBLE AND VISUAL ALARMS AUDIBLE AND VISUAL ALARMS ❑15. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)WITHOUT FLOW ❑ I5. AUTOMATIC LINE LEAK DETECTOR 3 0 GPH TES SHUT OFF OR RESTRICTION ( T) ❑16.ANNUAL INTEGRITY TEST(0.1 GPH) ❑16.ANNUAL INTEGRITY TEST(0.1 GPH) ❑17. DAILY VISUAL CHECK ❑17. DAILY VISUAL CHECK VIII.DISPENSER CONTAINMENT DISPENSER CONTAINMENT ❑1.FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE ❑4,DAILY VISUAL CHECK DATE INSTALLED 469 ❑2.CONTINUOUS DISPENSER PAN SENSOR+AUDIBLE AND VISUAL ALARMS ❑5.TRENCH LINER/MONITORING ®3.CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR ❑6 NONE 469 DISPENSER+AUDIBLE AND VISUAL ALARMS IX.OWNER/OPERATOR SIGNATURE I certify that the intonnation provided herein is true and accurate to the best ofmy knowledge. SIGNATURE OF OWNER/OPERATOR r DATE 470 NAME OF OWNER/OPRATOR(print) U 471 TITLE OF OWNER/OPERATOR 472 Jaginder Lal Permit Number(For local use only) 473 Permit Approved(For local use only) 474 Permit Expiration mate(For local use only) 475 UPCF(12/99 revised) 12 Formerly SWRCB Form B