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UNIFIED PROGRAM CONSOLIDATED FORM TANKS UNDERGROUND STORAGE TANKS-TANK PAGE 2 VI.PIPING CONSTRUCTION Check au that I) Page of UNDERGROUND PIPING ABOVEGROUND PIPING SYSTEM TYPE 1.PRESSURE ❑2.SUCTION ❑3.GRAVITY 458 ❑1.PRESSURE ❑2. SUCTION ❑3.GRAVITY 459 CoxBTRUC.TloN ❑1.SINGLE WALL ❑3.LINED TRENCH ❑99.OTHER 46o ❑1.SINGLE WALL ❑95.UNKNOWN 462 hLANUFACiVRER 012.DOUBLE WALL ❑95.UNKNOWN ❑2.DOUBLE WALL E399.OTHER MANUFACTURER 14 r 461 MANUFACTURER 463 Q 1.BARE STEEL ❑6 FRP C-ONIPATIBLE w lw. MET ANUL ❑1.BARE STEEL ❑6.FRP COMPATIBLE W/1WYe METHANOL ❑2.STAINLESS STEEL [17.GALVANIZED STEEL ®Unku.tu ❑2. STAINLESS STEEL [17.GALVANIZED STEEL [13.PLASTIC COMPATIBLE W/CONTENTS 0 99 Other 0 3. PLASTIC COMPATIBLE W/CONTENTS 0 8.FLE_NIRLE(HDPE) ❑99. OTHER hr4.FIBERGLASS ❑S.FLEXIBLE(HDPE) ❑4.FIBERGLASS ❑9.CATHODIC PROTECTION ❑5.STEEL W/COATING ❑9.CATHODIC PROTECTION 464 ❑5. STEEL W/COATING ❑95.UNKNOWN 465 A'II.PIPING LEAs:DETECTION Check A that apply)(.A descri tion of die monitocing shall be submitted to the local agency UNDERGROUND PIPING ABOVEGROUND PIPING 467 SINGLE WALL PIPING 466 SINGLE WALL PIPING PRESSURIZED PIPING(Check all that apply): PRESSURIZED PIPING(Check all that apply) ®1 ELECII20NIC.LINE LEAI+DI?TECTOR 3 0 GPH TEST\\ITH ALTIO]?LTh1P SHCtT ❑1. ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP OFF FOR LEAK,SYSTEM FAILURE,AND SYSTEM DISCONNECTION+ OFF L AND 1SYSTMIS AM17RE.-AND SYSTEM DISCONNEc'1TON+ ISCONH AUDIBLE AND VISUAL ALARMS. ❑2.MONTHLY 0.2 GPH TEST ❑2.MONTHLY 0.2 GPH TEST ❑3.ANNUAL INTEGRITY TEST(O.1GPH) ❑3.ANNUAL INTEGRITY TEST(O.IGPH) 0 4. DAILY VISUAL CHECK CONVENTIONAL SUCTION SYSTEMS CONVENTIONAL SUCTION SYSTEMS(Check all that apply) ❑ S.DAILY VISUAL MONITORING OF PUMPING SYSTEM+TRIENNIAL PIPING 0 5.DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM INTEGRITY TEST(0.1 GPH) SAFE SUCTION SYSTEMS(NO VALUES IN BELOW GROUNDPII'ING): [16. TRIENNIAL INTEGRITY TEST(0.1 GPH) 7.SELF MONITORING SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): ❑7. SELF MONITORING GRAVITY FLOW 0 9.BIENNIAL INTEGRITY TEST(0.1 GPH) GRAVITY FLOW(Check all that apply): ❑8.DAILY VISUAL MONITORING [19.BIENNIAL INTEGRITY TEST(0.1 GPH) SECONDARILY CONTAINED PIPING SECONDARILY CONTAINED PIPING PRESSURIZED PIPING(Check all that apply): PRESSURIZED PIPING(Check all that soly): 10.CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL 10.CONTINUOUS TURBINE AND 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 C'b. AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM O b AUTO TOPPUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM DISCONNECTION Oc. NO AUTO PUMP SHUT OFF Oc NO AUTO PUMP SHUT OFF 7(11. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)WITH FLOW SHUT []11. AUTOMATIC LEAK DETECTOR OFF OR RESTRICTION [312. ANNUAL INTEGRITY TEST(0.t GPH) [3 12. ANNUAL INTEGRITY TEST(O.I GPH) SUCTION/GRAVITY SYSTEM SUCTION/GRAVTTY SYSTEM ®13. CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS E313. 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• ❑t4. CONTINUOUS SUBLE V PSE SOR WITHOUT AUTO PUMP SHUT OFF AUDIBLE AND VISUAL ALARMS ❑15. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)WITHOUT FLOW ®15. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST) SHUT OFF OR RESTRICTION ❑t6.ANNUAL INTEGRITY TEST(0.t GPH) ❑16.ANNUAL INTEGRITY TEST(0.1 GPH) ❑17. DAILY VISUAL CHECK ❑17. DAILY VISUAL CHECK VIIL DISPENSER CONTAINMENT 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 3.CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR 0 6.NONE 469 DISPENSIRi+AUDIBLE AND VISUAL ALARh1S IX.OWNERIOPERATOR SIGNATURE I certify that the' ation provided herein is true and ace to to the Int of my knowledge. 4-0 SII ATURE OWNER/ PERATOR DATE r- r V 4-1 TITLE 0 OWNER/OPE TOR dp ; NAME •O ER/OP TOR ri t) t _ Permit Number(For local use only) 473 Permit Approved(For local We only) 494 Pmait Ecle[ation Dace(Far local we only) 4?s UPCF(1ZJ99 revised) 12 Formerly SWRCB Form B