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UNIFIED PROGRAM CONSOLIDATED FORM TANKS UNDERGROUND STORAGE TANKS-TANK PAGE 2 1 VI.PIPING CONSTRUCTION check ell thea l Page 2 of 2 UNDERGROUND PIPING ABOVEGROUND PIPING SYSTEM TYPE W 1.PRESSURE ❑2.SUCTION ❑3.GRAVITY 45B ❑L PRESSURE [12. SUCTION ❑3.GRAVITY 459 CONSTRUCTION ❑l.SINGLE WALL [13.LINED TRENCH ❑99.OTHER 460 ❑L SINGLE WALL ❑95.UNKNOWN 462 MANUFACTURER®2.DOUBLE WALL ❑95.UNKNOWN ❑2.DOUBLE WALL ❑99.OTHER MANUFACTURER SMITH FIBERGLASS 461 MANUFACTURER 463 ❑1.BARE STEEL ®6.FRP COMPATIBLE w/loo�A METHANOL ❑1.BARE STEEL ❑6.FRP COMPATIBLE W/100%METHANOL ❑2.STAINLESS STEEL ❑7.GALVANIZED STEEL ❑Unknown ❑2. STAINLESS STEEL ❑7.GALVANIZED STEEL ❑3.PLASTIC COMPATIBLE W/CONTENTS ❑99. Other ❑3. PLASTIC COMPATIBLE W/CONTENTS [18.FLEXIBLE(HDPE) [199. OTHER ❑4.FIBERGLASS [18.FLEXIBLE(HDPE) ❑4. FIBERGLASS ❑9.CATHODIC PROTECTION ❑5.STEEL W/COATING ❑9.CATHODIC PROTECTION 464 ❑5. STEEL W/COATING ❑95.UNKNOWN 465 VII.PIPING LEAK DETECTION(Check all that (Adescritionofthemonitoring shailbesubmitted tothe local a .) UNDERGROUND PIPING ABOVEGROUND PIPING SINGLE WALL PIPING 466 SINGLE WALL PIPING 467 PRESSURIZED PIPING(Check all that apply): PRESSURIZED PIPING(Check a0 that apply): ❑1.ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST wrm AUTO PUMP SHUT ❑1. ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP OFF FOR LEAK,SYSTEM FAILURE,AND SYSTEM DISCONNECTION+ SHUT OFF FOR LEAK,SYSTEM FAILURE,AND SYSTEM DISCONNECTION+ AUDIBLE AND VISUAL ALARMS. AUDIBLE AND VISUAL ALARMS. ❑2.MONTHLY 0.2 GPH TEST ❑2. MONTHLY 0.2 GPH TEST ❑3.ANNUAL INTEGRITY TEST(0.1 GPH) ❑3.ANNUAL INTEGRITY TEST(0.I GPH) [14. DAILY VISUAL CHECK CONVENTIONAL SUCTION SYSTEMS CONVENTIONAL SUCTION SYSTEMS(check all that apply) ❑5.DAILY VISUAL MONITORING OF PUMPING SYSTEM+TRIENNIAL PIPING INTEGRITY TEST(0.1 GPH) ❑5. DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM SAFE SUCTION SYSTEMS(NO VALUES IN BELOW GROUNDPIPING): ❑6.TRIENNIAL INTEGRITY TEST(0.1 GPH) ❑7.SELF MONITORING SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): GRAVITYFLOW [17.SELF MONITORING ❑9.BIENNIAL INTEGRITY TEST(0.1 GPH) GRAVITY FLOW(Check all that apply): ❑8. DAILY VISUAL MONITORING ❑9. BIENNIAL INTEGRITY TEST(0.1 GPH) SECONDARILY CONTAINED PIPING SECONDARILY CONTAINED PIPING PRESSURIZED PIPING(Check a0 that apply): PRESSURIZED PIPING(Check all that apply): 10. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL 10.CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL ALARMS AND(Check one) ALARMS AND(Check one) ❑a. AUTO PUMP SHUT OFF WHEN A LEAK OCCURS ❑a AUTO PUMP SHUT OFF WHEN A LEAK OCCURS ®b. AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM ❑b AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM DISCONNECTION DISCONNECTION ❑c.NO AUTO PUMP SHUT OFF ❑c NO AUTO PUMP SHUT OFF ®11. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)$ FLOW SHUT OFF OR RESTRICTION ❑11.AUTOMATIC LEAK DETECTOR ®12. ANNUAL INTEGRITY TEST(0.1 GPH) ❑12. ANNUAL INTEGRITY TEST(0.1 GPH) SUCTION/GRAVITY SYSTEM SUCTION/GRAVITY SYSTEM ❑13. CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS ❑13. CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS EMERGENCY GENERATORS ONLY(Chock all that apply) EMERGENCY GENERATORS ONLY(Chock an that apply) ❑14.CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF• ❑14. CONTINUOUS SUMP SENSOR WITH AUTO PUMP SHUT OFF AUDIBLE AND VISUAL ALARMS AUDIBLE AND VISUAL ALARMS ❑15. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)WITHOUT FLOW SHUT OFF OR RESTRICTION ❑15. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST) ❑16.ANNUAL INTEGRITY TEST(0.1 GPH) ❑16.ANNUAL INTEGRITY TEST(0.1 GPH) ❑17. DAILY VISUAL CHECK ❑17.DAILY VISUAL CHECK VIII.DISPENSER CONTAINMENT DISPENSER CONTAINMENT ❑1.FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE ❑4.DAILY VISUAL CHECK DATE INSTALLED 46N ®2.CONTINUOUS DISPENSER PAN SENSOR+AUDIBLE AND VISUAL ALARMS ❑5.TRENCH LINER/MONITORING 2003 0 3.CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR ❑6.NONE 469 DISPENSER+AUDIBLE AND VISUAL ALARMS DL OWNER/OPERATOR SIGNATURE I cam'y that the information provided herein is true and acetnate to the best of my knowledge. SIGNA OWNER/OPERATOR DATE azo NAME O O R/OPRATOR(print) 471 TITLE OF OWNER/OPERATOR 472 KAREN DHINGSA FACILITY MANAGER Permit Namber(For local use only) 473 Permit Approved(For local use only) 474 Permit Expiration Date(For local ttse only) 475 UPCF(12/99 revised) 12 Formerly SWRCB Form B