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'1 UNIFIED PROGRAM CONSOLIDATED FORM UNDERUND STORAGE TANKS -'*K PAGE 2 TANK VL PIPING CONSTRUCTION (Check ail that apply) Page o` UNDERGROUND PIPING SYSTEM TYPE 19 1. PRESSURE ❑ 2. SUCTION ❑ 3. GRAVITY 458 CONSTRUCTION 1 ❑ 1. SINGLE WALL [13, LINED TRENCH ❑ 99, OTHER 450 MANUFACTURER ® 2. DOUBLE WALL ❑ 95. UNKNOWN MANUFACTURER 451 ❑ 1. BARE STEEL ® 6. FRP COMPATIBLE w1100% METHANOL ❑ 2. STAINLESS STEEL ❑ 7. GALVANIZED STEEL ❑ UKNOWN ❑ 3. PLASTIC COMPATIBLE W1 CONTENTS ❑ 99. OTHER ❑ 4. FIBERGLASS ❑ 8. FLEXIBLE (HDPE) ❑ 5. STEEL WICOATING ❑ 9, CATHODIC PROTECTION 464 VIL PIPING LEAK DETECTION (Check all that apply) (A d UNDERGROUND PIPING SINGLE WALL PIPING 465 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 (0.1 GPH) CONVENTIONAL SUCTION SYSTEMS [15. DAILY VISUAL MONITORING OF PUMPING SYSTEM -TRIENNIAL PIPING INTEGRITY TEST (G.1 GPH) SAFE SUCTION SYSTEMS (NO VALUES IN BELOW GROUNDPIPING): [17, 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 one) ❑ a. AUTO PUMP SHUT OFF WHEN A LEAK OCCURS ❑ b. AUTO PUMP SHUT OFF FOR LEAKS, SYSTEM FAILURE AND SYSTEM DISCONNECTION Oc. NO AUTO PUMP SHUTOFF 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) ❑ 14. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF -AUDIBLE AND VISUALALARMS ❑ 15. AUTOMATIC LINE LEAK DETECTOR (3.0 GPH TEST) WITHOUT FLOW SHUT CFF CR RESTRICTION ❑ 16. ANNUAL INTEGRITY TEST (0.1 GPH) ❑ 17. DAILY VISUAL CHECK ABOVEGROUND PIPING ❑ 1. PRESSURE [12, SUCTION ❑ 3. GRAVITY 459 ❑ 1. SINGLE WALL ❑ 95. UNKNOWN 462 ❑ 2. DOUBLE WALL ❑ 99.OTHER MANUFACTURER 463 ❑ 1. BARE STEEL ❑ 6. FRP COMPATIBLE Wfl 00% METHANOL [:12. STAINLESS STEEL ❑ 7, GALVANIZED STEEL ❑ 3. PLASTIC COMPATIBLE W/ CONTENTS ❑ S. FLEXIBLE {HOPE) ❑ 99. OTHER ❑ 4. FIBERGLASS ❑ 9. CATHODIC PROTECTION ❑ 5. STEEL WICOATING [195, UNKNOWN 465 alion of the monitorino orooram shall be submitted to the local aaencv.1 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 [13. ANNUAL INTEGRITY TEST (O.lGPH) ❑ 4. 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): ❑ 7. SELF MONITORING GRAVITY FLOW (Check all that apply): [J8. DAILY VISUAL MONITORING E]9. 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 CFF FOR LEAKS, SYSTEM FAILURE AND SYSTEM DISCONNECTION ❑c NO AUTO PUMP SHUT OFF ❑ 11. AUTOMATIC LEAK DETECTOR [112. ANNUAL INTEGRITY TEST (0.1 GPH) SUCTIONIGRAVITY SYSTEM ❑ 13. CONTINUOUS SUMP SENSOR -AUDIBLE AND VISUAL ALARMS EMERGENCY GENERATORS ONLY (Check all that apply) ❑ 14. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF -AUDIBLE AND VISUAL ALARMS ❑ 15. AUTOMATIC LINE LEAK DETECTOR (3.0 GPH TEST) ❑ 16. ANNUAL INTEGRITY TEST (0.1 GPH) ❑ 17. DAILY VISUAL CHECK VIII. DISPENSER CONTAINMENT DISPENSER 01. FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE ❑ 4. DAILY VISUAL CHECK CONTAINMENT DATE INSTALLED 46a [12. CONTINUOUS DISPENSER PAN SENSOR+AUDIBLE AND VISUALALARMS ❑ 5. TRENCH LINER 1 MONITORING 12198 [13. CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR DISPENSER + El 6, NONE 469 AUDIBLE AND VISUAL ALARMS IX. OWNERIOPERATOR SIGNATURE 1 certlfy that the infor tion rovide rain is e a accurate to the best of my knowledge_ SIGNATU W E T DATE 47D 113102 NAME OF OWNERIOPRATOR (print) TITLE OF OWNERIOPERATOR 472 Dennis Smith Operations & Environmental Specialist Permit Number (For local use only) 473 Permit Approved {For local use only) Permit Expiration Dale (For local use only) 475 UPCF (1199 revised) Formerly SWRCB Form B