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UNIFIED PROGRAM CONSOLIDATED FORM TANKS UNDERGROUND STORAGE TANKS -TANK PAGE 2 CUPAFORM (4/99) Formerly SWRCB Form B VL PIPING CONSTRUCTION (CMcxNgMapppp UNDERGROUND PIPING ABOVEGROUND PIPING SYSTEM TYPE ❑ 1 PRESSURE 2, SUCTION ❑ 3. GRAVITY ❑ 1. PRESSURE ❑ 2. SUCTION ❑ 3. GRAVITY SINGLE WALL 113. UNEDTRENCH ❑ N OTHER ❑ 1. SINGLE WALL ❑ BS UNKNOWN CONSTRUCTIOW MANUFACTURER .❑.,/L G� 2 DOUBLE WALL ❑ 95. UNKNOWN Cl 2. DOUBLE WALL ❑ N. OTHER MANUFACTURER MANUFACTURER ❑ 1. SARESTEEL ❑ 8, FRP COMPATIBLE WI 100%METHANOL ❑ 1. RARE STEEL ❑ 5. FRP COMPATIBLE W/100%METHANOL MATERIALSAND ❑ 2. STAINLESS STEEL ❑ T. GALVANIZED STEEL ❑ 2. STAINLESS STEEL ❑ T. GALVANIZED STEEL CORROSION PROTECTION ❑- 33. PLASTIC COMPATIBLE WITH CONTENTS ❑95. UNKNOWN 0 PLASTIC COMPATIBLE WITH CONTENTS ❑ B. FLEXIBLE (MOPE) ❑99. OTHER h0//1 FIBERGLASS ❑ 8. FLEKIBLE(HDPE) ON OTHER ❑ 4. FIBERGLASS ❑ 9. CATHODIC PROTECTION LIPS. STEEL W/ COATING ❑ 9, CATHODIC PROTECTION 10 5. STEEL WI COATING ❑ O. UNKNOWN MI. PIPING LEAK DETECTION (CMck NMat apply) UNDERGROUND PIPING ABOVEGROUND PIPING SINGLE WALL PIPING SINGLE WALLPIPING PRESSURIZED PIPING (Check ad Mal apply): PRESSURIZED PIPING (Check all Mel apply): ❑ 1. ELECTRONIC UNE 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 • AUDIBLE AND VISUAL SYSTEM FAILURE. AND SYSTEM DISCONNECTION ;'-AUDIBLE AND VISUAL ALARMS ALARMS ❑ 2. MONTHLY 0.2 GPM TEST ❑ 2. MONTHLY 0.2 GPM TEST ❑ 3. ANNUAL INTEGRITY TEST (0.1 GPM) ❑ 3 ANNUAL INTEGRITY TEST (01 GPM) ❑ 4. DAILY VISUAL CHECK CONVENTIONAL SUCTION SYSTEMS'. CONVENTIONAL SUCTION SYSTEMS (Check N Mat IMPW, Cl 5 DAILY VISUAL MONITORING OF PUMPING SYSTEM • TRIENNIAL PIPING INTEGRITY ❑ 5. DAILY VISUALMONITORING OF PIPING AND PUMPING SYSTEM TEST (0I GPM) ❑ S. TRIENNIAL INTEGRITY TEST (01 GPM) SAFE SUCTION SYSTEMS (NO VALVES IN BELOW GROUND PIPING)SAFE SUCTION SYSTEMS IND VALVES IN BELOW GROUND PIPING): ❑ T SELFMONITORING ❑ T. SELFMONITONING GRAVITY FLOW'. GRAVITY FLOW (Check N Mel apply)' ❑ 9. BIENNIAL INTEGRITY TEST 10.1 GPM) ❑ 8. DAILYVISUALMONITORING ❑ 9. BIENNIAL INTEGRITY TEST 10.1 GPM) SECONDARILY CONTAINED PIPING SECONDARILY CONTAINED PIPING PRESSURIZED PIPING(Chock a8 that apply)' PRESSURIZED PIPING (CM all that apply' 10. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL ALARMS AND 10. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL ALARMS AND ICheG{arM) (Chea anal ❑ e. AUTO PUMP SHUT OFF WHEN A LEAK OCCURS ❑ a. AUTO PUMP SHUT OFF MEN A LEAK OCCURS ❑ E AUTO PUMP SHUT OFF FOR LEAKS, SYSTEM FAILURE AND SYSTEM ❑ 0. AUTO PUMP SHUT OFF FOR LEAKS, SYSTEM FAILURE AND SYSTEM DISCONNECTION DISCONNECTION ❑ a NO AUTO PUMP SHUT OFF ❑ a NO AUTO PUMP SHUT OFF ❑ 11 AUTOMATIC LINE LEAK DETECTOR (3.0 GPM TEST) WITH FLOW SHUT OFF OR ❑ 11. AUTOMATIC LEAK DETECTOR RESTRICTION ❑ 12. ANNUAL INTEGRITY TEST 10.1 GPM) ❑ 12. ANNUAL INTEGRITY TEST III 1 GPM) SU CT ONIGRAVITY SYSTEM: SUCTIONIGRAVITY SYSTEM: 13. CONTINUOUS SUMP SENSOR v AUDIBLE AND VISUAL ALARMS ❑ 13. CONTINUOUS SUMP SENSOR F AUDIBLE AND VISUAL ALARMS EMERGENCY GENERATORS ONLY (CM k a8 Mal apply) EMERGENCY GENERATORS ONLY (CM k all Mal 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 ❑ 15. AUTOMATIC UNE LEAK DETECTOR (30 GPM TEST) RESTRICTION ❑ 18. ANNUAL INTEGRITY TEST (O. I GPM) ❑18. ANNUAL INTEGRITY MST (al GPM) ❑ 17. DAILY VISUAL CHECK ❑ 1T. DAILY VISUAL CHECK VK DISPENSER CONTAINMENT DISPENSER CONTAINMENT ❑ 1. FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE ❑ 4, DAILYVISUALCHECK DATEIN TALLED❑ 2. CONTINUOUS DISPENSER PAN SENSOR - AUDIBLE AND VISUAL ALARMS ❑ 5. TRENCHUNERIMONITORING G C_ ❑ 3. CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR DISPENSER -AUDIBLE AND VISUAL ALARMS ❑ B. NONE DL OWNER/OPERATOR SIGNATURE 1 uraly Mal We inlormaaon pmvideE herein la true Me M We Wa of my iWom i, SIGNATURE OF OWNERIOPERATOR DATE ©/.3 NAME OF OWNER/OPERATOR(pmM TITLE OF OWNER)OPERATOR CC^^PemM Parma N.lWe(For local Pu onW Pmmk ApAppMel(Fa foul Vee oM/% Ex,amak i 0.0(FdbcY ufa aHyl CUPAFORM (4/99) Formerly SWRCB Form B