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s UNIFIED PROGRAM CONSOLIDATED FORM 0\' �' TAN K UNDERGWUND STORAGE TANKS - *K PAGE 2 ASA" Page _ of VI. PIPING CONSTRUCTION (Check all that apply) UNDERGROUND PIPING SYSTEM TYPE 0 1. PRESSURE [12 SUCTION ❑ 3. GRAVITY CONSTRUCTION 1 ❑ 1. SINGLE WALL ❑ 3. LINED TRENCH ❑ 99. OTHER MANUFACTURER 0 2 DOUBLE WALL ❑ 95. UNKNOWN MANUFACTURER Teleflex ❑ 1. BARE STEEL 216. FRP COMPATIBLE wit ow. METHANOL ❑ 2. STAINLESS STEEL ❑ 7. GALVANIZED STEEL ❑ UKNOWN ❑ 3. PLASTIC COMPATIBLE WI CONTENTS 1-199. OTHER [14. FIBERGLASS ❑ 8. FLEXIBLE (HDPE) ❑ 5. STEEL WICOATNG [19. CATHODIC PROTECTION 464 VII. PIPING LEAK DETECTION (Check all that aF SINGLE WALL PIPING ABOVEGROUND PIPING 458 ❑ 1. PRESSURE ❑ 2. SUCTION ❑ 3. GRAVITY 459 460 ❑ 1. SINGLE WALL El 95. UNKNOWN 462 ❑ 2 DOUBLE WALL ❑ 99. OTHER 461 (A 466 PRESSURIZED PIPING (Check all thatapply): ❑ 1. ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP SHUT OFF FOR LEAK, SYSTEM FAILURE, AND SYSTEM DISCONNECTION +AUDIBLE AND VISUAL ALARMS. ❑ 2. MONTHLY 0.2 GPH TEST [13, ANNUAL INTEGRITY TEST (G.1GPH) CONVENTIONAL SUCTION SYSTEMS ❑ 5. DAILY VISUAL MONITORING OF PUMPING SYSTEM +TRIENNIAL PIPING INTEGRITY TEST (0.1 GPH) SAFE SUCTION SYSTEMS (NO VALUES tN BELOW GROUNDPIPING): ❑ 7. SELF MONITORING GRAVITY FLOW [19. BIENNIAL INTEGRITY TEST (0.1 GPH) SECONDARILY CONTAINED PIPING PRESSURIZED PIPING (Check all that apply): 10. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL ALARMS AND (Check ane) [3a. AUTO PUMP SHUT OFF WHEN A LEAK OCCURS b. AUTO PUMP SHUT OFF FOR LEAKS, SYSTEM FAILURE AND SYSTEM DISCONNECTION ®c. NO AUTO PUMP SHUT OFF ❑ 11. AUTOMATIC LINE LEAK DETECTOR (3.0 GPH TEST) WITH FLOW SHUTOFF OR RESTRICTION 12. ANNUAL INTEGRITY TEST (0.1 GPH) SUCTIONIGRAVITY SYSTEM ❑13. CONTINUOUS SUMP SENSOR -AUDIBLE AND VISUAL ALARMS EMERGENCY GENERATORS ONLY (Check all that apply) [114 CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT CFF -AUDIBLE AND VISUAL ALARMS [115. AUTOMATIC LINE LEAK DETECTOR (3.0 GPH TEST) WITHOUT FLOW SHUT OFF OR RESTRICTION ❑ 16. ANNUAL INTEGRITY TEST (0.1 GPH) [117. DAILY VISUAL CHECK MANUFACTURER 463 1. BARE STEEL ❑ 6. FRP COMPATIBLE WY OW. METHANOL ❑ 2. STAINLESS STEEL ❑ 7. GALVANIZED STEEL 3, PLASTIC COMPATIBLE W1 CONTENTS ❑ 8. FLEXIBLE (HDPE) [199. OTHER ❑ 4. FIBERGLASS ❑ 9. CATHODIC PROTECTION ❑ 5. STEEL WICOATING ❑ 95. UNKNOWN 465 lotion of the monitoring program shall be submitted to the local agency,) SINGLE WALL PIPING 467 PRESSURIZED PIPING (Check all that apply). ❑ 1. ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP SHUT OFF FOR LEAK, SYSTEM FAILURE, AND SYSTEM DISCONNECTION + AUDIBLE AND VISUAL ALARMS. ❑ 2. MONTHLY 0.2 GPH TEST ❑ 3. ANNUAL INTEGRITY TEST (0.1 GPH) [14 DAILY VISUAL CHECK CONVENTIONAL SUCTION SYSTEMS (Check all that apply) ❑ 5. DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM E16 TRIENNIAL INTEGRITY TEST (0.1 GPH) SAFE SUCTION SYSTEMS (NO VALVES IN BELOW GROUND PIPING): [17. SELF MONITORING GRAVITY FLOW (Check all that apply): ❑ 8. DAILY VISUAL MONITORING E39. BIENNIAL INTEGRITY TEST (0.1 GPH) SECONDARILY CONTAINED PIPING PRESSURIZED PIPING (Check all that apply): 10. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL ALARMS AND )Check one) ❑ a AUTO PUMP SHUT OFF WHEN A LEAK OCCURS ❑ b AUTO PUMP SHUT OFF FOR LEAKS, SYSTEM FAILURE AND SYSTEM DISCONNECTION ❑c NO AUTO PUMP SHUT OFF ❑ 11, AUTOMATICLEAK DETECTOR ❑ 12. ANNUAL INTEGRITY TEST (0.1 GPH) SUCTIONIGRAVITY SYSTEM El 13. CONTINUOUS SUMP SENSOR -AUDIBLE ANDVISUALALARMS EMERGENCY GENERATORS ONLY (Check all that apply) ❑ 14. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF + AUDIBLE AND VISUAL ALARMS [115, AUTOMATIC LINE LEAK DETECTOR (3A GPH TEST} ❑ 16. ANNUAL INTEGRITY TEST (0.1 GPH) [117. DAILY VISUAL CHECK VIII. DISPENSER CONTAINMENT DISPENSER 01. FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE ❑ 4. DAILY VISUAL CHECK CONTAINMENT DATE INSTALLED 466 El 2, CONTINUOUS DISPENSER PAN SENSOR+AUDIBLE AND VISUAL ALARMS [3 5. TRENCH LINER f MONITORING ❑ 3. CONTINUOUS OOUS DISPENSER PAN VISUAL ALARMS SENSOR WITH AUTO SHUT OFF FOR DISPENSER + [36. NONE 12/98 IX. OWNER/OPERATOR SIGNATURE I certify that the inform ion Ovide cin is e a accurate to the best of my knowledge. SIGNATU E DATE 113/02 NAME OF OWNERIOPRATOR (print) TITLE OF OWNER/OPERATOR Dennis Smith 0 erationS & Environmental S eciafist 473 Permit Approved (For local use only) Permit Expiration Oate or local use only) Permit Number (For local use only) pp 475 UPCF (1199 revised) 469 Formerly SWRCB Form B