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UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANKS - TANK PAGE 2 TANKS VI,PIPING CONSTRUCTION(Checka7thatappW Pace UNDERG12. � ��--w. .:. SYSTEM ABOVEGROUND PIPING 1. PRESSURE 2. SUCTION ❑ 3. GRAVITY ❑ 1. PRESSURE 1. SINGLE WALL ❑ 3. LINED TRENCH 2. SUCTION ❑ 3. GRAVITY CONSTR ❑99. OTHER JR 1. SINGLE WALL MANUFADOUBLE WALL ❑9 . UNKNOWN ❑95. UNKNOWN NUFACTURER _ ❑ 2. DOUBLE WALL ❑99. OTHER MANUFACTURER ❑ 1.BARE STEEL ❑ B. FRP COMPATIBLE WI 100%METHANOL MATERIALS AND ❑ 2. STAINLESS STEEL ❑ 7.GALVANIZED STEEL 1. BARE STEEL ❑ 6. FRP COMPATIBLE Wl 100%METHANOL CORROSION ❑ 2. STAINLESS STEEL ❑ 7. GALVANIZED STEEL PROTECTION 3. PLASTIC COMPATIBLE WITH CONTENTS 1195. UNKNO'4N ❑ 3. PLASTIC COMPATIBLE WITH CONTENTS ❑ 8. FLEXIBLE(HDPE) ❑99. OTHER ❑4. FIBERGLASS ❑ 8. FLEXIBLE(HDPE) ❑99. OTHER. ❑ 4. FIBERGLASS ❑ 5. STEEL WI COATING ❑ 9.CATHODIC PROTECTION119. CATHODIC PROTECTION ❑ 5. STEEL W/COATING ❑95. UNKNOWN VII.PIPING LEAK DETECTION(Check ail that e,)*) UNDERGROUND PIPING SINGLE YlALL PIPING - - ABOVEGROUND PIPING•-L- PRESSURIZED PIPING(Check all Inat apply): SINGLE WALL PIPING ❑ 1. ELECTRONIC LINE LEAK DETECTOR 3.0 GPM TEST WITH AUTO PUMP SHUT OFF FOR PRESSURIZED PIPING(Check all that apply): - LEAK,SYSTEM FAILURE,AND SYSTEM DISCONNECTION AUDIBLE AND VISITAL ❑ 1 ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP SHUT OFF FOR LEAK, ALARMS SYSTEM FAILURE,ANO SYSTEM DISCONNECTION+AU018LE AND VISUAL ALARMS ❑ 2. MONTHLY 0.2 GPM TEST ❑ 2. MONTHLY 0.2 GPM TEST ❑ 3.ANNUAL INTEGRITY TEST(0 1 GPM) ❑ 3. ANNUAL INTEGRITY TEST(0.1 GPM) ❑ 4. DAILY VISUAL CHECK CONVENTIONAL SUCTION S'fSTEMS. CONVENTIONAL SUCTION SYSTEMS(Check all that a ❑ 5. DAILY VISUAL MONITORING OF PUMPING SYSTEM-TRIENNIAL PIPING INTEGRITY TEST(0 i GPH) 5. GAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): ❑ 8. TRIENNIAL INTEGRITY TEST(0.1 GPM) ❑ 7. SELF MONITORING SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): GRAVITY FLOW 7. SELF MONITORING ❑ 9. BIENNIAL INTEGRITY TEST(0 1 GPM) GRAVITY FLOW(Check as that apply): ❑ 8. DAILY VISUAL MONITORING SECONDARILY CONTAINED PIPING C19. BIENNIAL INTEGRITY TEST(0.1 GPM) PRESSURIZEO PIPING(Check all that apply): SECONDARILY CONTAINED PIPING 10. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL ALARMS AND PRESSURIZED PIPING(Check all that apply): (Check one) 11 a AUTO PUMP SHUT OFF A LEAK OCCURS 10.CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL ALARMS AND(check one) 11 o AUTO PUMP SHUT OFF FOR ❑ a. AUTO PUMP SHUT OFF WHEN A LEAK OCCURS OR LEAKS.SYSTEM FAILURE AND SYSTEM D-SCONNECTION ❑ D. AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM DISCONNECTION ❑ C. NO AUTO PUMP SHUT OFF ❑ c. NO AUTO PUMP SHUT OFF C111. AUTOMATIC LINE LEAK DETECTOR(3.0 GPM TEST)WITH FLOW SHUT OFF OR RESTRICTION ❑ 11. AUTOMATIC LEAK DETECTOR ❑ 12. ANNUAL INTEGRITY TEST(0 1 GPM) SUCTION/GRAVITY SYSTEM ❑ 12. ANNUAL INTEGRITY TEST(0.1 GPM) 13. CONTINUOUS SUMP SENSOR•AUDIBLE AND VISUAL ALARMS SUCTION/GRAVITY SYSTEM: . ❑ 13. CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS EMERGENCY GENERATORS ONLY(Check all that apply) - [RESTRICTON 14. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF+AUDIBLE AND EM ERGENCY GENERATORS ONLY(Check aA that appy) VISUALALARMS ❑ 14. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF+AUDIBLE AND VISUAL 15. AUTOMATIC LINE LEAK DETECTOR(3.0 GPM TEST)WITHOUT FLOW SHUT OFF OR ALARMS ❑ 15. AUTOMATIC LINE LEAK DETECTOR(3.0 GPM TEST) 16.ANNUAL INTEGRITY TEST(0.1 GPM) 17, DAILY VISUAL CHECK 016. ANNUAL INTEGRITY TEST(0.1 GPM) 17. DAILY VISUAL CHECK VHL DISPENSER CONTAINMENT DISPENSER CONTAINMENT ❑ 1. FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE DATE INSTALLED ❑ 2.CONTINUOUS DISPENSER PAN SENSOR+AUDIBLE AND VISUAL ALARMS ❑ 4. DAILY VISUAL CHECK NER/MONITORING 113. CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR DISPENSER+AUDIBLE AND VISUAL ALARMS 8.NONE Myy I cert4 that the informaho ea herein is true an accurstst of mIX.OYV)iER)OPERATOR SIGNATURE y knowledge. SIGNATURE OF O PERATO DATE + NAME OF G E ERATOR(print) ��- TITLE OF OWNER OPERATOR / t 1 Permit NumSer(Forlocal use or Permit Approved(For local use only) Perna Expiration Date(Farlocal use only) I 'UPAFORM(4199) Formerly SWRCB Form 6