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