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l'"!) 6 4 o-) qvl'- <br /> UNIFIED PROGRAM (UP) FORM tali"NO-7 IV-Q- <br /> UNDERGROUND STORAGE TANKS - TANK PAGE 2 <br /> VI.PIPING CONSTRUCTION(Check all that apply) Page W <br /> UNDERGROUND PIPING ABOVEGROUND PIPING <br /> SYSTEM TYPE ®1.PRESSURE 0 2.SUCTION 03.GRAVITY 456 0 1.PRESSURE 0 2. SUCTION 0 3.GRAVITY 459 <br /> CONSTRUCTION 0 1.SINGLE WALL 0 3.LINED TRENCH 099.OTHER 460 0 1.SINGLE WALL 0 95.UNKNOWN 462 <br /> MANUFACTURER 0 2.DOUBLE WALL 0 95.UNKNOWN J 0 2.DOUBLE WALL 0 99.OTHER <br /> MANUFACTURER r U <br /> 461 MANUFACTURER 463 <br /> MATERIALS AND 1 egg STEEL SME 6.FRP wN00% (31 ggRE STEEL ❑6.FRP COMPATIBLE W/11)0%METHANOL <br /> CORROSION <br /> PROTECTION O 2.STAINLESS STEEL 0 7.GALVANIZED STEEL 02.STAINLESS STEEL 0 7.GALVANIZED STEEL <br /> 0 95.UNKNOWN <br /> 0 3.PLASTIC COMPATIBLE W/CONTENTS 0 8.FLEXIBLE(HDPE) 03.PLASTIC COMPATIBLE 0 g FLEXIBLE(HDPE)0 95.UNKNOWN <br /> W/CONTENTS <br /> 0 4.FIBERGLASS 0 9.CATHODIC PROTECTION 0 4. FIBERGLASS 0 9.CATHODIC PROTECTION <br /> 0 S.STEEL W/COATING 0 99.OTHER tsa 0 5. STEEL W/COATING 0 99. OTHER 465 <br /> VII.PIPING LEAK DETECTION(Check all that app) )(A description of the monitoring ram shall be submitted to me local agency.) <br /> UNDERGROUND PIPING ABOVEGROUND PIPING <br /> SINGLE WALL PIPING 466 SINGLE WALL PIPING 467 <br /> PRESSURIZED PIPING(Check all that apply): PRESSURIZED PIPING(Check all that apply): <br /> 0 1.ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP 0 1. ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP <br /> SHUT OFF FOR LEAK,SYSTEM FAILURE,AND SYSTEM SHUT OFF FOR LEAK,SYSTEM FAILURE,AND SYSTEM <br /> DISCONNECTION+AUDIBLE AND VISUAL ALARMS. DISCONNECTION+AUDIBLE AND VISUAL ALARMS. <br /> 0 2.MONTHLY 0.2 GPH TEST 02. MONTHLY 0.2 GPH TEST <br /> 0 3.ANNUAL INTEGRITY TEST(0.1 GPH) 0 3.ANNUAL INTEGRITY TEST(0.1 GPH) 0 4. DAILY VISUAL CHECK <br /> CONVENTIONAL SUCTION SYSTEMS(Check all mat apply) CONVENTIONAL SUCTION SYSTEMS(Check all that apply) <br /> 0 5.DAILY VISUAL MONITORING OF PUMPING SYSTEM+TRIENNIAL PIPING 0 5. DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM <br /> INTEGRITY TEST(0.1 GPH) <br /> 0 6. TRIENNIAL INTEGRITY TEST(0.1 GPH) <br /> SAFE SUCTION SYSTEMS(NO VALUES IN BELOW GROUNDPIPING): SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): <br /> 0 7.SELF MONITORING 0 T SELF MONITORING <br /> GRAVITY FLOW GRAVITY FLOW(Check all mat apply): <br /> 0 9.BIENNIAL INTEGRITY TEST(0.1 GPH) 08.DAILY VISUAL MONITORING 09.BIENNIAL INTEGRITY TEST(0.1 GPH) <br /> SECONDARILY CONTAINED PIPING SECONDARILY CONTAINED PIPING <br /> PRESSURIZED PIPING(Check an that apply): PRESSURIZED PIPING(Check all mat apply): <br /> 10. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL 10. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL <br /> ALARMS AND(Check one) ALARMS AND(Check one) <br /> 0 a. AUTO PUMP SHUT OFF WHEN A LEAK OCCURS 0 a AUTO PUMP SHUT OFF WHEN A LEAK OCCURS <br /> ®b. AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND 0 b AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM <br /> SYSTEM DISCONNECTION DISCONNECTION <br /> \ Oc. NO AUTO PUMP SHUT OFF Oc NO AUTO PUMP SHUT OFF <br /> 1 )9,11. AUTOMATIC LEAK DETECTOR(3.0 GPH TEST) WITHFLOW SHUT OFF ❑11. AUTOMATIC LEAK DETECTOR <br /> 012. ANNUAL INTEGRITY TEST(0.1 GPH) 012. ANNUAL INTEGRITY TEST(0.1 GPH) <br /> SUCTIOWGRAVITY SYSTEM SUCTION/GRAVITY SYSTEM <br /> 013. CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS 013. CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS <br /> EMERGENCY GENERATORS ONLY(Check all that apply) EMERGENCY GENERATORS ONLY(Check all Mat apply) <br /> 0 14. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF0 14. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF' <br /> AUDIBLE AND VISUAL ALARMS AUDIBLE AND VISUAL ALARMS <br /> 0 15. AUTOMATIC LEAK DETECTOR(3.0 GPH)WFTHOUT FLOW SHUT OFF 015. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST) <br /> 0 16.ANNUAL INTEGRITY TEST(0.1 GPH) 0 17. DAILY VISUAL CHECK 0 16.ANNUAL INTEGRITY TEST(0.1 GPH) 0 17. DAILY VISUAL CHECK <br /> VIII.DISPENSER CONTAINMENT <br /> DISPENSER CONTAINMENT 0 1.FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE 0 4.DAILY VISUAL CHECK <br /> DATE INSTALLED 466 0 2.CONTINUOUS DISPENSER PAN SENSOR+AUDIBLE AND VISUAL ALARMS 0 S.TRENCH LINER/MONITORING <br /> [13.CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR 0 6.NONE 469 <br /> DISPENSER+AUDIBLE AND VISUAL ALARMS <br /> IX.OWNERIOPERATOR SIGNATURE <br /> I partly that the information proyided heroin is We and a=rate to Me best of my knov4edge. <br /> SIGNATURE OF OWNER/ R DATE470 <br /> _ZZ <br /> -0 <br /> NAME OF OWNIE ) TITLE OFOWNERIOPERATOR 472 <br /> Cynthia H. a ri General Manager, Retail Services <br /> OFFICIAL USE ONLY Permit Number 473 1 Pennit Approved 474 1 Permit Expiration Date 475 <br /> • <br /> UP FORM(1/2000 Version) 3 Formerly SWRCB Form B <br /> SBC UST-B.doc <br />