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k 114 i ( t_ <br /> UNIFIED PROGRAM (UP) FORM <br /> UNDERGROUND STORAGE TANKS - TANK PAGE 2 <br /> VI.PIPING CONSTRUCTION(Check all that apply) Page Of <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 O 1.SINGLE WALL O 95.UNKNOWN 462 <br /> MANUFACTURER 0 2.DOUBLE WALL 0 95.UNKNOWN 0 2.DOUBLE WALL 0 99.OTHER <br /> MANUFACTURER LN v 1 D IJJ 461 MANUFACTURER 463 <br /> MATERIALS AND 0 1.BARE STEEL O B.FRP COMPATIBLE W/t00% <br /> CORROSION METHANOL 01.BARE STEEL ❑6.FRP COMPATIBLE W1100%METHANOL <br /> PROTECTION 0 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 g FLEXIBLE(HDPE) 95.UNKNOWN <br /> W/CONTENTS <br /> 0 4.FIBERGLASS 0 9.CATHODIC PROTECTION 0 4. FIBERGLASS 0 9.CATHODIC PROTECTION <br /> 0 5.STEEL W/COATING 0 99.OTHER 464 0 5. STEEL W/COATING 0 99. OTHER 465 <br /> VII.PIPING LEAK DETECTION(Check an that apply)(A descdPUM of the monitoring program shall be Submitted m the local agency.) <br /> UNDERGROUND PIPING ABOVEGROUND PIPING <br /> SINGLE WALL PIPING 466 SINGLE WALL PIPING 467 <br /> PRESSURIZED PIPING(Check au met apply): PRESSURIZED PIPING(Check all met apply): <br /> ❑1.ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP ❑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 mat 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 [17. SELF MONITORING <br /> GRAVITY FLOW GRAVITY FLOW(Check all mat apply): <br /> 0 9.BIENNIAL INTEGRITY TEST(0.1 GPH) O8.DAILY VISUAL MONITORING 09.BIENNIAL INTEGRITY TEST(0.1 GPH) <br /> SECONDARILY CONTAINED PIPING SECONDARILY CONTAINED PIPING <br /> PRESSURIZED PIPING(Check all mat 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 ane) <br /> 0 a. AUTO PUMP SHUT OFF WHEN A LEAK OCCURS 0 a AUTO PUMP SHUT OFF WHEN A LEAK OCCURS <br /> 0 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 /> �11. AUTOMATIC LEAK DETECTOR(3.0 GPH TEST) WITHFLOW SHUT OFF 0 11. AUTOMATIC LEAK DETECTOR <br /> 12. ANNUAL INTEGRITY TEST(0.1 GPH) 0 12. ANNUAL INTEGRITY TEST(0.1 GPH) <br /> SUCTIONGRAVITY 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 that 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)WITHOUT FLOW SHUT OFF 015. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST) <br /> [116.ANNUAL INTEGRITY TEST(0.1 GPH) 0 17. DAILY VISUAL CHECK 0 16.ANNUAL INTEGRITY TEST(0.1 GPH) [117. 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 468 0 2.CONTINUOUS DISPENSER PAN SENSOR+AUDIBLE AND VISUAL ALARMS O 5.TRENCH LINER/MONITORING <br /> 0 3.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 artily that the InfonnaU n provided h is We and a=rata M the best of my kmW edge. <br /> SIGNATURE OF OWNER/Id R DATE G,� 470 <br /> l -G <br /> NAME OF OWNE ) TITLE OF OWNER/OPERATOR 472 <br /> Cynthia H Madrid General Manager, Retail Services <br /> OFFICIAL USE ONLY Permit Number 473 1 Permit Approved 474 1 Permit Expiration Date 475 <br /> UP FORM(1/2000 Version) 3 Formerly SWRCB Form B <br /> SBC UST-B.doc <br />