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,! ` • UNIFIED PROGRAM CONSOLIDATE )RM • UNDERGROUND STORAGE TANKS - TANK PAGE 2 'TANK PIPING CO NSTRUCTION Check all lltata>>1 Page of UNDERGROUND PIPING ABOVEGROUND PIPING SYSTEM TYPE ®1.PRESSURE ❑2.SUCTION GRAVITY 458 ❑1.PRESSURE ❑2. SUCTION CONSIRUC770N ❑1.SINGLE WALL ❑3.LINED TRENCH ❑99.OTHER 460 ❑3.GRAVI'T'Y 459 ❑ I.SINGLE WALL ❑95.UNKNOWN 462 MANUFACTURER ®2.DOUBLE WALL ❑95.UNKNOWN ❑2.DOUBLE WALL ❑99.OTHER MANUFACTURER TELEFLEX 461 V MANUFACTURER 463 I.BARE STEEL ❑6.FRP COMPATIBLE w/l00% ME'111ANOI, ❑1.BARE STEE1. ❑6.FRP COMPATIDLE w/loo%ME711ANOL ❑2.STAINLESS ST'EGL ❑7.GALVANIZED STEEL I ❑Unknown ❑2. STAINLESS STEEL ❑7.GALVANIZED STEEL ❑3.PLASTIC COMPATIBLE W/CONTENTS ❑99. Other ❑3. PLASTIC COMPATIBLE W/CONTENTS ❑8.FLEXIBLE(HDPE) ❑99. OTHER ®4.FIBERGLASS ❑8.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 apply)(A description of the monitoring program shall be submitted to the local agency.) UNDERGROUND PIPING ABOVEGROUND PIPING SINGLE WALL PIPING 46o SINGLE.WALL PIPING PRESSURIZED PIPING(Check all that apply): 407 PRESSURIZED PIPING(Check all Orat apply): ❑ 1.ELECTRONIC LINE LEAK DE'FECT'OR 3.0 GPH TEST WITH AUTO PUMP STRUT' OFF FOR LEAK,SYSTEM FAILURE,AND SYSTEM DISCONNECTION+ 111. ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP AUDIBLE AND VISUAL ALARMS. SHUT OFF FOR LEAK,SYSTEM FAILURE,AND SYSTEM DISCONNECTION 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(0.1 GPI 1) ❑4. DAILY VISUAL CHECK CONVENTIONAL SUCTION SYSTEMS CONVENTIONAL SUCTION SYSTEMS(Check all that apply) El 5.DAILY VISUAL MONITORING OF PUMPING SYSTEM+TRIENNIAL PIPING pP y) INTEGRITY TEST(0.1 GPH) ❑5. DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM SAFE,SUCTION S YSTEMS(NO VALUES IN BELOW GROUNDPIPING): ❑6. TRIENNIAL INTEGRITY TEST(0.1 GPH) ❑7.SELF MONITORING GRAVITY FLOW SAFE SUCTION S YSTEMS(NO VALVES IN BELOW GROUND PIPING): 13 7. SELF MONITORING ❑9.BIENNIAL INTEGRITY TEST(U.I GPH) GRAVITY FLOW(Check all that apply) PP Y) ❑8. DAILY VISUAL MONITORING ❑9. BIENNIAL INTEGRITY TEST(0.1 GPH) SECONDARILY CONTAINED PIPING SECONDARILY CONTAINED PIPING ('KIiSSl1RIZED PIPING(Check all that apply): PRESSURIZED PIPING(Check all that apply): 1(1. CON'T'INUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL ALARMS AND(Check one) 10 CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL 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 DISCONNECTION ❑b AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM Sc NO AUTO PUMP SHUT OFF DISCONNECTION ® I I AUTOMATIC LINE LEAK DE'T'ECTOR(3.0 GPH TEST)WITH FLOW SHUT ❑c NO AUTO PUMP SHUT OFF 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(Check all that apply) ❑14 CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF• EMERGENCY GENERATORS ONLY(Check all that apply) AUDIBLE AND VISUAL ALARMS ❑14. CONTINUOUS SUMP SENSOR WTT'HOUT AUTO PUMPS}(UT OFF ❑ 15 AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)WITH OUT FLOW AUDIBLE AND VISUAL ALARMS 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 ® I.FLOAT MECHANISM THAT SHUTS 01•'F SHEAR VALVE DATE INSTALLED 468 ❑4.DAILY VISUAL CHECK ❑2.CONTINUOUS DISPENSER PAN SENSOR+AUDIBLE AND VISUAL ALARMS ❑5.TRENCH LINER/MONITORING 1994 ❑3.CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR DISPENSER+A()DIBLE AND VISUAL ALARMS ❑6.NONE 469 LX.OWNER/OPERA'T'OR SIGNATURE I certify flint the hrfomtation provided herein is true mut accurate to the best of my knowledge. SI TUBE OF OWNE PERATOR DATE di 3 - 1 q-0 3 470 NAME:OF OWNE OPRATOR(print) SANDYEDWARDS TITLE OFOWNER/OPERATOR ^ (� 472 o T�. j (`\U J1 a Permit Number(For heal use only) 473 Permit Approved(For local use only) �1t �� Permit Expiration Date(For Iiokal use only) 475 UPCF(1/99 revised) Formerly SWRCB Form B