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UNIFIED PROGRAM CONSOLIDATED FOi TANKS UNDERGROUND STORAGE TANKS -TANK PAGE 2 VI.PIPING CONSTRUCTION(Check all that apply) Page 6 of 7 UNDERGROUND�I�PING ABOVEGROUND P[PING 459 SYSTEM TYPE 1.PRESSURE ❑ 2.SU3.GRAVITY a58 ❑ 1.PRESSURE ❑2.SUCTION ❑3.GRAVITY CONSTRUCTION ❑ 1.SINGLE WALL [:13.LINED TRENCH ❑99.OTHER - ❑ I.SINGLE WALL E]95.UNKNOWN 462 2.DOUBLE WALL ❑95.UNKNOWN 461 ❑ 2.DOUBLE WALL ❑99.OTHER 463 MANUFACTURER MANUFACTURER ❑ I.BARE STEEL ❑6.FRP COMPATIBLE W too-/.METHANOL ❑ I.BARE STEEL ❑6.FRP COMPATIBLE W 100%METHANOL ❑2.STAINLESS STEEL ❑ 7.GALVANIZED STEEL [1 2.STAINLESS STEEL ❑7.GALVANIZED STEEL nc r n.rtntnvrnr F1 PLASTIC COMPATIBLE W/CONTENTS ❑ 95.UNKNOWN ❑ PLASTIC COMPATIBLE W/CONTENTS ❑F-1 4.FIBERGLASS 8.FLEXIBLE(HDPE) ❑ 99.OTHER ❑4.FIBERGLASS [18.FLEXIBLE(HDPE) E]99.OTHER ❑464 5.STEEL W/COATING ❑ 9.CATHODIC PROTECTION 465 F15.STEEL W/COATING ❑ 9.CATHODIC PROTECTION VII.PIPING LEAK DETECTION(Check all that apply)(A description of the monitoring program shall be suburined to the local agency.) UNDERGROUND PIPING ABOVEGROUND PIPING SINGLE WALL PIPING 466 SINGLE WALL PIPING 467 PRESSURIZED PIPING(Check all that appy): PRESSURIZED PIPING(Check all that apply): ❑ 1.ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP SHUT OFF ❑ 1.ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP SHUT OFF FOR LEAK.SYSTEM FAILURE.AND SYSTEM DISCONNECTION+AUDIBLE AND FOR LE KA-SSYYSSTS M 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 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+TRIENNIEAL PIPING INTEGRITY TEST(0.1 GPH) ❑6.TRIENNIAL INTEGRITY TEST(0.1 GPH) SAFE SUCTION SYSTEMS(NO VALUES IN BELOW GROUNDPIPING): SAFE SUCTION SYSTEMS(NO VALUES IN BELOW GROUNDPIPING): ❑ 7.SELF MONITORING ❑7.SELF MONITORING GRAVITY FLOW GRAVITY FLOW(Check all that apply): ❑9.BIENNIAL INTEGRITY TEST(0.1)GPH ❑ S.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 appy): 10.CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL I0.CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL ALARMS AND(Check one) ALARMS AND(Check one) �f a.AUTO PUMP SHUT OFF WHEN A LEAK OCCURS E] a.AUTO PUMP SHUT OFF WHEN A LEAK OCCURS ♦♦�� ❑b.AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM ❑It.AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM DISCONNECTION DISCONNECTION ❑c ❑ c.NO AUTO PUMP SHUT OFF .NO AUTO PUMP SHUT OFF x11.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) ❑ 12.ANNUAL INTEGRITY SUCT[ONlGRAVITY SYSTEM SUCTION/GRAVITY SYSTEM TEST(O.l GPH) ❑ 13.CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS E] 13.CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS EMERGENCY GENERATORS ONLY(Check all that apply) EMERGENCY GENERATORS ONLY(Check all that apply) ❑ 14.CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF• ❑ 14.CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF AUDIBLE AND VISUAL ALARMS AUDIBLE AND VISUAL ALARMS ❑ 15.AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)WITHOUT FLOW ❑ SFIU f.OPF OR IICRESTRICTIONLINAK DETECTOR(3.0 GPH TEST)WITHOUT FLOW SHUT OFF OR RESTRICTION ❑ 16.ANNUAL INTEGRITY TEST(0.1 GPH) ❑ 16.ANNUAL INTEGRITY TEST(0.l GPH) ❑ 17.DAILY VISUAL CHECK ❑ 17.DAILY VISUAL CHECK VIII.DISPENSER CONTAINh1ENT DISPENSER CONTAINMENT ❑ 1.FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE ❑4.DAILY VISUAL CHECK DATE INSTALLED 468 ❑2.CONTINUOUS DISPENSER PAN SENSOR+AUDIBLE AND VISUAL ALARMS ❑ 5.TRENCH LINER/MONITORING M9 to K3.CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR ❑6.NONE I 469 DISPENSER+AUDIBLE AND VISUAL ALARMS IX.0 R4ER/OPERATOR SIGNATURE I certify that the information prosided herein is true and acnoate to the bat of my knowledge. }-c SIGNATURE OF OWNER/OPERATOR DATE NAME OF OWNER/OPERATOR(print) 471 TITLE OF OWNER/OPERATOR 472 Permit Approved(For local use only) 474 Pemut cus ation Date(For local e only), 415 PermitNurnber(For local use only) 473 . 12/31/1996_ PT0006493 EE0003804 UPCF(12/99 revised) �- �'