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UNIFIED PROGRAM CONSOLIDATED FORM (�JJ S161D3 <br />TANK <br />IVNK 2 <br />UNDERGMUND STORAGE TANKS - PAGE <br />VI. PIPING CONSTRUCTION (Check all that apply) ge _ of <br />UNDERGROUND PIPING <br />ABOVEGROUND PIPING <br />SYSTEM TYPE 01. PRESSURE D 2. SUCTION D 3. GRAVITY 458 <br />[11. PRESSURE D 2. SUCTION D 3. GRAVITY 459 <br />CONSTRUCTION/ D 1. SINGLE WALL D 3. LINED TRENCH 0 99. OTHER 468 <br />0 1. SINGLE WALL D 95. UNKNOWN 462 <br />MANUFACTURER 0 2. DOUBLE WALL 0 95, UNK 0 N 1 <br />0 2. DOUBLE WALL [199. OTHER <br />MANUFACTURER O SMS <br />MANUFACTURER 463 <br />❑ 1. BARE STEEL 0 6. FRP COMPATIBLE W/t90% MErHANOL <br />[11. BARE STEEL D 6. FRP COMPATIBLE W1100% METHANOL <br />D 2. STAINLESS STEEL D 7. GALVANIZED STEEL D UKNOWN <br />D 2. STAINLESS STEEL D 7. GALVANIZED STEEL <br />D 3. PLASTIC COMPATIBLE WI CONTENTS 0 99. OTHER <br />0 3. PLASTIC COMPATIBLE W/ CONTENTS D 6. FLEXIBLE (HDPE) D 99. OTHER <br />D 4, FIBERGLASS D 8. FLEXIBLE (HDPE) <br />D 4. FIBERGLASS 0 9. CATHODIC PROTECTION <br />❑ 5. STEEL W/COATING D 9. CATHODIC PROTECTION 464 <br />[15 STEEL WICOATING 0 95. UNKNOWN 465 <br />VII. PIPING LEAK DETECTION (Check all that apply) (A deacdplied <br />of the monitoring program shall be submitted to the local agency.) <br />UNDERGROUND PIPING <br />ABOVEGROUND PIPING <br />SINGLE WALL PIPING 466 <br />SINGLE WALL PIPING 467 <br />PRESSURIZED PIPING (Check all that apply): <br />PRESSURIZED PIPING (Check all that apply): <br />01. ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP SHUT OFF FOR <br />01. ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP SHUT OFF FOR <br />LEAK, SYSTEM FAILURE, AND SYSTEM DISCONNECTION+ AUDIBLE AND VISUAL <br />LEAK, SYSTEM FAILURE, AND SYSTEM DISCONNECTION+ AUDIBLE AND VISUAL <br />ALARMS. <br />ALARMS. <br />D2. MONTHLY 0.2 GPH TEST <br />02. MONTHLY 0.2 GPH TEST <br />D3. ANNUAL INTEGRITY TEST (0.1 GPH) <br />03. ANNUAL INTEGRITY TEST (0 1 GPH) <br />04. DAILY VISUAL CHECK <br />CONVENTIONAL SUCTION SYSTEMS <br />CONVENTIONAL SUCTION SYSTEMS (Check all that apply) <br />D5. DAILY VISUAL MONITORING OF PUMPING SYSTEM + TRIENNIAL PIPING INTEGRITY <br />05. DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM <br />TEST (0.1 GPH) <br />SAFE SUCTION SYSTEMS (NO VALUES IN BELOW GROUNDPIPING): <br />[36. TRIENNIAL INTEGRITY TEST (0.1 GPH) <br />07. SELF MONITORING <br />SAFE SUCTION SYSTEMS (NO VALVES IN BELOW GROUND PIPING): <br />GRAVITY FLOW <br />07. SELF MONITORING <br />D9. BIENNIAL INTEGRITY TEST (0.1 GPH) <br />GRAVITY FLOW (Check all that apply): <br />U8. DAILY VISUAL MONITORING <br />[19. BIENNIAL INTEGRITY TEST (0.1 GPH) <br />SECONDARILY CONTAINED PIPING <br />SECONDARILY CONTAINED PIPING <br />PRESSURIZED PIPING (Check all that apply): <br />PRESSURIZED PIPING (Check all that apply): <br />10. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLEAND VISUAL ALARMS AND <br />10, CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUALALARMS AND <br />(Checkow) <br />(Check one) <br />0 a. AUTO PUMP SHUT OFF WHEN A LEAK OCCURS <br />Ca AUTO PUMP SHUT OFF WHEN A LEAK OCCURS <br />[31c. AUTO PUMP SHUT OFF FOR LEAKS, SYSTEM FAILURE AND SYSTEM <br />D b AUTO PUMP SHUT OFF FOR LEAKS, SYSTEM FAILURE AND SYSTEM <br />DISCONNECTION <br />DISCONNECTION <br />®c. NOAUTO PUMP SHUT OFF <br />Uc NO AUTO PUMP SHUT OFF <br />�.t <br />cy 11. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST) WITH FLOW SHUTOFF OR <br />011 AUTOMATIC LEAK DETECTOR <br />I " RESTRICTION <br />012. ANNUAL INTEGRITY TEST (0.1 GPH) <br />[112. ANNUAL INTEGRITY TEST (0A GPH) <br />SUCTION/GRAVITY SYSTEM <br />SUCTIONIGRAVITY SYSTEM <br />D13, CONTINUOUS SUMP SENSOR+ AUDIBLE AND VISUAL ALARMS <br />D13. CONTINUOUS SUMP SENSOR+AUDIBLE ANDVISUALALARMS <br />EMERGENCY GENERATORS ONLY (Check all that apply) <br />EMERGENCY GENERATORS ONLY (Check all that apply) <br />D14. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF + AUDIBLE AND <br />SS MP SENSOR WITHOUT AUTO PUMP SHUT OFF + AUDIBLE AND <br />D14. CONTINUOUS <br />VISUALALARMS <br />ONTINUO <br />MS <br />015. AUTOMATIC UNE LEAK DETECTOR (3.0 GPH TESTI WITHOUT FLOW SHUT OFF OR <br />0 15, AUTOMATIC LINE LEAK DETECTOR (3.0 GPH TEST) <br />RESTRICTION <br />0 16. ANNUAL INTEGRITY TEST (0.1 GPH) <br />[116. ANNUAL INTEGRITY TEST (0.1 GPH) <br />017. DAILY VISUAL CHECK <br />017. DAILY VISUAL CHECK <br />VIII. DISPENSER CONTAINMENT <br />DISPENSER ®1. FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE D 4. DAILY VISUAL CHECK <br />CONTAINMENT <br />DATE INSTALLED 468 E12. CONTINUOUS DISPENSER PAN SENSOR+AUDIBLE AND VISUAL ALARMS [15. TRENCH LINER/ MONITORING <br />[33. CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR DISPENSER + 0 6. NONE 469 <br />12/9$ AUDIBLE AND VISUAL ALARMS <br />IX. OWNER/OPERATOR SIGNATURE <br />t the infor a' pr vided is into nal urate to the best of my knowledge. <br />470 <br />E05T WN /OP R DATE <br />8/03 <br />NAME OF OW OP OR (print) <br />TITLE Jr OWNER/OPERATOR 472 <br />Dennis Smith <br />Operations & Environmental Specialist <br />esprit Number (For local use only) 473 Permit Approved (Far local use only) Permit Expiration Date (For local use only) <br />475 <br />UPCF (1/99 revised) 40 0 Formerly SWRCB Form B <br />