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UNIFIED PROGRAM CONSOLIDATED FORM TANKS UNDERGROUND STORAGE TANKS - TANK PAGE 2 A.PIPING CONSTRUCTION(C),eck b Natapply) UNDERGROUND PIPING ASOVEGROUND PIPING SYSTEM TYPE ❑ 1 PRESSURE ❑ 2. SUCTION ❑ 3. GRAVITY ❑ 1. PRESSURE ❑ 2. SUCTION ❑ 3. GRAVITY CONSTRUCTION/ ❑ 1. SINGLE WALL ❑ 3. LINED TRENCH ❑99. OTHER ❑ 1. SINGLE WALL 1195. UNKNOWN - MANUFACTURER DOUBLE WALL ❑95. UNKNOWN ❑ 2. DOUBLE WALL [IN. OTHER MANUFACTURER MANUFACTURER ❑ 1,BARE STEEL FRP COMPATIBLE WI 100%METHANOL ❑ I. BARE STEEL ❑ B. FRP COMPATIBLE W1 100%METHANOL CORROSIOO N IAND 132. STAINLESS STEEL ❑ T. GALVANIZED STEEL ❑ 2. STAINLESS STEEL 11T. GALVANIZED STEEL CORROS PROTECTION ❑ 3. PLASTIC COMPATIBLE WITH CONTENTS El 95. UNKNOWN ❑ 3. PLASTIC COMPATIBLE KITH CONTENTS ❑ B. FLEXIBLE(HDPE) ❑9B. OTHER . FIBERGLASS ❑ B. FLEXIBLE(HOPE) ❑99. OTHER ❑ 4. FIBERGLASS ❑ 9. CATHODIC PROTECTION ❑ 5. STEEL WI COATING ❑ 9. CATHODIC PROTECTION ❑ 5. STEEL WI COATING IJ 96, UNKNOWN NI.PIPING LEAK DETECTION(Check aBMet apply) UNDERGROUND PIPING ABOVEGROUND PIPING SINGLE WALL PIPING SINGLE WALL PIPING PRESSURIZED PIPING(Clack aA that appy).' PRESSURIZED PIPING(Check ak that appy): ❑ 1. ELECTRONIC LINE LEAK DETECTOR 3.0 GPM TEST WITM AUTO PUMP SHUT OFF FOR ❑ 1. ELECTRONIC LINE LEAK DETECTOR 3.0 GPM TEST WITH AUTO PUMP SHUT OFF FOR LEAK, LEAK.SYSTEM FAILURE.AND SYSTEM DISCONNECTION+AUDIBLE AND VISUAL SYSTEM FAILURE.AND SYSTEM DISCONNECTION;AUDI BLE AND VISUAL ALARMS ALARMS ❑ 2. MONTHLY 02 GPM TEST ❑ 2. MONTHLYGEl 3, ANNUAL INTEGRITY TEST(0.1 GPM) ❑ 3. ANNUAL INTEGRITY ITY TTESEST(0.1 GPM) ❑ 4, DAI LY VISUAL CHECK CONVENTIONAL SUCTION SYSTEMS: CONVENTIONAL SUCTION SYSTEMS(Check all Mat apply): ❑ 5. DAILY VISUAL MONITORING OF PUMPING SYSTEM TRIENNIAL PIPING INTEGRITY ❑ S. DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM TEST(0.1 GPM) ❑ B. TRIENNIAL INTEGRITY TEST 10.1 GPM) SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING) SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING)'. ❑ T SELF MONITORING ❑ T. SELF MONITORING GRAVITY FLOW' GRAVITY FLOW(Check ell Rat apON)' ❑ 9. BIENNIAL INTEGRITY TEST(0 1 GPM) ❑ e. DAILY VISUAL MONITORING ❑ 9. BIENNIALINTEGRITY TEST OA GPM) SECONDARILY CONTAINED PIPING SECONDARILY CONTAINED PIPING PRESSURIZED PIPING(Check all that apply): PRESSURIZED PIPING(Check all that appy): 10.CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL ALARMS AND (Chao one) 10.CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL ALARMS AND(Uerk ane) ❑ a. AUTO PUMP SHUT OFF WHEN A LEAK OCCURS ❑ a. AUTO PUMP SHUT OFF WHEN A LEAK OCCURS ❑ 0. AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM ❑ DISCONNECTION p, AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM DISCONNECTION ❑ a NO AUTO PUMP SHUT OFF ❑ c. NO AUTO PUMP SHUT OFF 11 AUTOMATIC LINE LEAK DETECTOR(3.0 GPM TEST)WITH FLOW SHUT OFF OR ❑ 11 AUTOMATIC LEAK DETECTOR RESTRICTION ❑ 12. ANNUAL INTEGRITY TEST 101 GPM) ❑ 12. ANNUAL INTEGRITY TEST to.1 GPM) SUCTION/GRAVITY SYSTEM: SUCTIOWGRAVITY SYSTEM'. ❑ 13. CONTINUOUS SUMP SENSOR-AUDIBLE AND VISUAL ALARMS ❑ 13. CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS EMERGENCY GENERATORS ONLY(Check ap that aPpN) EMERGENCY GENERATORS ONLY(Check all Mat apply) 14. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF+AUDIBLE AND ❑ 14. CONTINUOUS SUMP SENSOR VATHOUT AUTO PUMP SHUT OFF+AUDIBLE AND VISUAL VISUALALARMS ALARMS ❑ 15.AUTOMATIC LINE LEAK DETECTOR 13.0 GPM TEST)WITHOUT FLOW SHUT OFF OR ❑ 15.AUTOMATIC LINE LEAK DETECTOR Go GPM TEST) RESTRICTION ❑ 15.ANNUAL INTEGRITY MST(0.1 GPM) ❑ 19. ANNUAL INTEGRITY TEST IDA GPM) ❑ 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 DATEINSTALLED ❑ 2. CONTINUOUS DISPENSER PAN SENSOR+AUDIBLE AND VISUAL ALARMS ❑ 5. TRENCH UNER I MONITORING ❑ 3. CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR DISPENSER+AUDIBLE AND VISUALALARMS ❑ B. NONE M.OWNER/OPERATOR SIGNATURE I ceniy Nat Ma Inrprmatan provided habin Ic tita and li.rab to Ne Eesl 01 my k.Wl d, SIGNATURE OF OWNERIOPERATOR GATE NAME OF OWNEWOPERATOR(pMn TITLE OF ONME"PERATOR Parmil Number(Fortmal use only) Pamil APpmsad(Fakcal use wW Permk Eviradw Data(Forbcal use only) CUPAFORM(4199) Fomlerly SWRCB Form B