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U N I F PROGRAM CONSOLIDATED FOR TANKS II UNDERGROUND STORAGE TANKS -TANK PAGE 2 P � VI.PIPING CONSTRUCTION(Check SM that apply) ABOVEGROUND PIPING ❑ 3. GRAVITY ❑ 2. SUCTION UNDERGROUND PIPING C3 3. GRAVITY ❑ 1. PRESSURE ❑g5. UNKNOWN SYSTEM T :I YPE 1. PRESSURE ❑ 2. SUCTION ❑ 3LINED TRENCH ❑99. OTHER ❑ 1. SINGLE WALL C3 gg OTHER ❑ 1. SINGLE WALL . C] 2, DOUBLE WALL CONSTRUCTION/ ❑95. UNKNOWN MANUFACTURER MANUFACTURER :] 2. DOUBLE WALL :1_ 6. FRP COMPATIBLE WI 700%METHANOL MANUFACTURER ❑ 1.BARE STEEL ❑ S. FRP COMPATIBLE W/100%METHANOL 0 2 STA STAINLESS STEEL ❑ 7. GALVANIZED STEEL ❑99 OTHER MATERIALS AND ❑ 2. STAINLESS STEEL ❑ 7. GALVANIZED STEEL C3 95. UNKNOWN ❑ 3. PLASTIC COMPATIBLE WITH CONTENTS a. FLEXIBLE(HOPE) a 9 CATHODIC PROTECTION CORROSION ❑ 3. PLASTIC COMPATIBLE`MTM CONTENTS [:14. FIBERGLASS 4. FIBERGLASS PROTECTIONC] 8 FLEXIBLE(HDPE) ❑99. OTHER ❑ 5. STC]95. UNKNOWN EEL'N/COATING ❑ 5. STEEL WI COATING ❑ 9. CATHODIC PROTECTION �y(hat applYi VII..PIPING LEAK DETECTION(Check ggOVEGROUNO PIPING SINGLE WALL PIPING UNDERGROUND PIPING all that apply): PRESSURIZED PIPING(CheckK. SINGLE WALL PIPING ❑ 1P SHUT OFF , ELECTRONIC LINE LEAK DETECTOR 3.0 GPM TEST WITH AUTO PUMP SMUT OFF FOR LEA PRESSURIZED PIPING(Check all that apply): ❑ OR 3.0 SYSTEM FAILURE.AND SYSTEM DISCONNECTION•AUOIBL.E AND VISUAL ALARM t LELECTRONIC LINE LEAK EAK.SYSTEM FAILURE.D AND SYSTEM DISCONNEC ON+AUDIBLE AND VISUAL FOR ❑ 2 MONTHLY 0.2 GPM TEST ALARMS ❑ 3. ANNUAL INTEGRITY EST(0.1 GPM) ❑ 2. MONTHLY 0.2 GPM TEST ❑ 4. DAILY VISUAL CHECK ❑ 3, ANNUAL INTEGRITY TEST(0.1 GPM) all that applYl: CONVENTIONAL SUCTION SYSTEMS(CAack CONVENTIONAL SUCTION SYSTEMS: UMPING SYSTEM•TRIENNIAL PIPING INTEGRITY ❑ 5. DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM ❑ 5. GAILY VISUAL MONITORING OF P ❑ S. TRIENNIAL INTEGRITY TEST(0.1 GPM) TEST(0.1 GPM) 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 FLOW(Check alt that apply): GRAVITY FLOW: ❑ S. DAILY VISUAL MONITORING ❑ 9. BIENNIAL INTEGRITY TEST(0.1 GPM) ❑ 9, BIENNIAL INTEGRITY TEST(0.1 GPM) SECONDARILY CONTAINED PIPING SECONDARILY CONTAINED PIPING PRESSURIZED PIPING(Check ad that apply): I PRESSURIZED PIPING(Check all that apPty): 10. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL ALARMS ANO 10.CONTINUOUS TUROINE SUMP SENSOR WITH AUDIBLE AND VISUAL ALARMS AND(ChaCK one (Check one) C] a, AUTO PUMP SHUT OFF WHEN A LEAK OCCURS JR a. AUTO PUMP SHUT OFF WHEN A LEAK OCCURS C1 b. AUTO PUMP SHUT OFF FOR LEAKS.SYSTEM FAILURE AND SYSTEM DISCONNECTION I C3 b. AUTO pump SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM ❑ c, NO AUTO PUMP SHUT OFF DISC ION K DETECTOR ❑ c, NO AUTO PUMP SHUT OFF 11, AUTOMATIC LEA 11. AUTOMATIC LINE LEAK DETECTOR(3.0 GPM EST)WITH FLOW SHUT OFF OR ❑ 12. ANNUAL INTEGRITY EST(0.1 GPM) RESTRICTION Cl 12. ANNUAL INTEGRITY TEST(0.1 GPM) SUCTIONIGRAVITY SYSTEM: SUCTIONIGRAVITY SYSTEM: C313. CONTINUOUS SUMP SENSOR•AUDIBLE AND VISUAL ALARMS ❑ 13. CONTINUOUS SUMP SENSOR•AUDIBLE AND VISUAL ALARMS EMERGENCY GENERATORS ONLY(Check all that applN EMERGENCY GENERATORS ONLY(Check ad that apply) E AN ALARMS ❑ 14. CONTINUOUS SUMP SENSOR NATHOUT AUTO PUMP SHUT OFF•AUDIBLE AND VISUAL C] 14. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF•AUDIBL ❑ 15 AUTOMATIC LINE LEAK DETECTOR(3.0 GPM TEST) VISUAL ALARMS C315. AUTOMATIC UNE LEAK DETECTOR(3.0 GPM TEST)WITHOUT FLOW SHUT OFF OR C318. ANNUAL INTEGRITY TEST(0.1 GPM) RESTRICTION ❑ 18. ANNUAL INTEGRITY TEST(0.1 GPM) ❑ 17, DAILY VISUAL CHECK ❑ 17, DAILY VISUAL CHECK VIII.DISPENSER CONTAINMENT ❑ 4. DAILY VISUAL CHECK DISPENSER CONTAINMENT ❑ 1. FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE [3 5. TRENCH LINER I MONITORING DATE INSTALLED ❑ 2. CONTINUOUS DISPENSER PAN SENSOR•AUDIBLE AND VISUAL ALARMS i n_1 A 0 9 6a 3. CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR DISPENSER•AUDIBLE AND VISUAL ALARMS C] d. NONE IX.OWNERIOPERATOR SIGNATURE i I caruty that Ne intormauon provided herein is true and acarata to lha best of my know) 9°- DATE SIGNATURE OF OWNERIOPERATOR TITLE OF pWNERIOPERATOR NAME OF OWNER/OPERATOR(print) permit Ekptrauon Date(Forlocal use only) Permit Number(For local use only) Perth Approved(For local use only) Formerly SWRCB Form B CUPAFORM(4199)