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UNIFIED PROGRAM CONSOLIDATED FORM TANKS UNDERGROUND STORAGE TANKS -TANK PAGE 2 VI.PIPINCs CONSTRUCTION(Check ap that appfA ABOVEGROUND PIPING UNDERGROUND PIPING ❑ 2. SUCTION ❑ 3. GRAVITY SYSTEM TYPE ❑ 1 PRESSURE ❑ 2. SUCTION ❑ 3. GRAVITY ❑ 1. PRESSURE ❑95. UNKNOWN CONSTRUCTION/ [I1. SINGLE WALL ❑ 3. LINED TRENCH ❑99. OTHER ❑ 1. SINGLE WALL ❑99 OTHER ❑ 2. DOUBLE WALL - MANUFACTURER ❑ 2. DOUBLE WALL ❑95- UNKNOWN MANUFACTURER MANUFACTURER ❑ S. FRP COMPATIBLE W1 100%METHANOL ❑ 1.BARE STEEL ❑ 6. FRP COMPATIBLE W1100%METHANOL ❑ 1. BARE STEEL ❑ 7 GALVANIZED STEEL MATERIALS AND [12. STAINLESS STEEL ❑ 7. GALVANIZED STEEL C12. STAINLESS STEEL CORROSION ❑ 3 PLASTIC COMPATIBLE HATH CONTENTS ❑95. UNKNOWN ❑ 3. PLASTIC COMPATIBLE WITH CONTENTS ❑ 8. FLEXIBLE(HDPE) 99. OTHER PROTECTION ❑ 9.CATHODIC PROTECTION ❑ 4. FIBERGLASS ❑ 8. FLEXIBLE(HDPE) 1199. OTHER ❑ 5. STEEL L COATING [195. UNKNOWN ❑ 5. STEEL W/COATING ❑ 9. CATHODIC PROTECTION VII.PIPING LEAK DETECTION(CheckaBthetappty) ' ABOVEGROUND PIPING UNDERGROUND PIPING SINGLE WALL PIPING SINGLE WALL PIPING PRESSURIZED PIPING(Check all that apply): PRESSURIZED PIPING(Check all that apply): PUMP ❑ 1. ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP SHUT OFF FOR ❑ 1 SYSTEM FAIL C LINE ALARMS AND SYSTEM LEAK TDISCO NECTION WITH AUTO EOAND V SUAL ALARMS LEAK, LEAK,SYSTEM FAILURE,AND SYSTEM DISCONNECTION+AUDIBLE AND VISUAL ❑ 2 MONTHLY IL GPH TEST ALARMS ❑ 2. MONTHLY 0.2 GPH TEST ❑ 3. ANNUAL INTEGRITY TEST(0.1 GPH) ❑ 3. ANNUAL INTEGRITY TEST(0.1 GPH) ❑ 4. DAILY VISUAL CHECK CONVENTIONAL SUCTION SYSTEMS(Check all that apply): CONVENTIONAL SUCTION SYSTEMS: ❑ 5. DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM ❑ 5 DAILY VISUAL MONITORING OF PUMPING SYSTEM+TRIENNIAL PIPING INTEGRITY ❑ 6. TRIENNIAL INTEGRITY TEST(0.1 GPH) TEST(0.1 GPH) SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): ❑ 7. SELF MONITORING ❑ 7. SELF MONITORING GRAVITY FLOWGRAVITY FLOW(Check all that apply): ❑ 9. BIENNIAL INTEGRITY TEST(0.1 GPH) ❑ 8. DAILY VISUAL MONITORING ❑ 9. BIENNIAL INTEGRITY TEST(0.1 GPH) SECONDARILY CONTAINED PIPING SECONDARILY CONTAINED PIPING PRESSURIZED PIPING(Check all that apply): PRESSURIZED PIPING(Check all that apply): 10. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL ALARMS AND 10.CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND V,SUAL ALARMS AND(check one) (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)WITH FLOW SHUT OFF OR ❑ 11. AUTOMATIC LEAK DETECTOR RESTRICTION ❑ 12. ANNUAL INTEGRITY TEST(0.1 GPH) C112. ANNUAL INTEGRITY TEST(0 t GPH) SUCTIONIGRAVITY SYSTEM: SUCTIONIGRAVITY SYSTEM: ❑ 13. CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS ❑ 13. CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS EMERGENCY GENERATORS ONLY(Check all that apply) EMERGENCY GENERATORS ONLY(Check as that appM ❑ 14. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF+AUDIBLE AND ❑ 14. CONTINUOUS SUMP SENSOR WITHOUT ALTO PUMP SHUT OFF+AUDIBLE AND VISUAL VISUAL ALARMS ALARMS ❑ 15. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)WITHOUT FLOW SHUT OFF OR ❑ 15. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST) RESTRICTION ❑ 16. ANNUAL INTEGRITY TEST(0.1 GPH) ❑ 16. ANNUAL INTEGRITY TEST(0.1 GPM) ❑ 'IT 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 ❑ 2. CONTINUOUS DISPENSER PAN SENSOR+AUDIBLE AND. __=_-_== 5 ❑ S. TRENCN L y VONITORING ❑ 3. CONTINUOUS DISPENSER PAN SENSOR WITH AUTO S'••______-__=E,qER+AUDIBLE AND V;-- El 6. NONE OL CVV%E1L0PEC- �S.-SVATURE I certify that the information provided herein is true and accurateto the best of my know+ecye SIGNATURE OF OWNER/OPERATOR - NAME OF OWNER/OPERATOR(pont) TITLE CF *.E:7PERATOR Permit dumber(For local use only) Permit Approved(For local use or)ynll Penna Expiration Date(For local use only) V CUPAFORM(4/99) Formerly SWRCB Form B