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.0 LQ /'7('[P UNIFIED PROGRAM CONSOLIDATED FORM TANKS UNDERGROUND STORAGE TANKS-TANK PAGE 2 VL PIPING CONSTRUCTION Choi a0 that Paw_of- UNDERGROUND PIPING ABOVEGROUND PIPING SYSTEM TYPE ❑1.PRESSURE ❑2.SUCTION 3.GRAVITY 458 ❑1.PRESSURE ❑2. SUCTION [13-GRAVITY 459 CONSTPUCT10N ❑I SINGLE WALL ❑3.LINED TRENCH ❑99.OTHER 460 ❑L SINGLE WALL ❑95.UNKNOWN 462 MANUFACTURER .DOUBLE WALL ❑95.UNKNOWN [12.DOUBLE WALL ❑99.OTHER FACTURER AO I MANUFACTURER 463 ❑L BARE STEEL ❑ COMPATIBLE w/t00% mETHANoL ❑L BARE STEEL ❑6.FRP COMPATIBLE Wllou%MEMANOL ❑2.STAINLESS STEEL (17.GALVANIZED STEEL ❑Unknown ❑2. STAINLESS STEEL ❑7.GALVANIZED STEEL ❑3.PLASTIC COMPATIBLE W/CONTENTS ❑99.Odra [13. PLASTIC COMPATIBLE W/CONTENTS [IS.FLEXIBLE(HDPE) ❑99. OTHER FIBERGLASS ❑8_FLEXIBLE(HDPE) ❑4. FIBERGLASS ❑9.CATHODIC PROTECTION ❑5.STEEL W/COATING ❑9.CATHODIC PROTECTION 464 [:15- STEEL W/COATING ❑95.UNKNOWN 465 VIL PIPING LEAK DETECTION(Chmkau that )(Adan ofthe pmormn shall be Ribmutedtothe lecal ) 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 ❑1. ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP OFF FOR LEAK,SYSTEM FAILURE,AND SYSTEM DISCONNECTION+ SHUT OFF FOR LEAK,SYSTEM FAILURE,AND SYSTEM DISCONNECTION+ AUDIBLE AND VISUAL ALARMS, AUDIBLE AND VISUAL ALARMS. ❑2.MONTHLY 0.2 GPH TEST ❑2_ MONTHLY 0.2 GPH TEST ❑3.ANNUAL INTEGRITY TEST(0.IGPH) ❑3.ANNUAL INTEGRrrY TEST(0.1GPH) ❑4. DAILY VISUAL CHECK CONVENTIONAL SUCTION SYSTEMS CONVENTIONAL SUCTION SYSTEMS(Check all dwapply) ❑5.DAILY VISUAL MONITORING OF PUMPING SYSTEM+TRIENNIAL PIPING ❑5. DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM INTEGRITY TEST(0.l GPH) SAFE SUCTION SYSTEMS(NO VALUES IN BELOW GROUNDPIPING): ❑6. TRIENNIAL INTEGRITY TEST(0.1 GPH) ❑7.SELF MONITORING SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): GRAVITY FLOW ❑7. SELF MONITORING ❑9.BIENNIAL INTEGRITY TEST(0.1 GPH) GRAVITY FLOW(Check all dmt apply): ❑8. DAILY VISUAL MONITORING ❑9. BIENNIAL INTEGRITY TEST(0.1 GPH) SECONDARILY CONTAINED PIPING SECONDARILY CONTAINED PIPING PRESSURIZED PIPING(Check all dal appy): PRESSURIZED PIPING(Check a0 that appy): 10. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL 10. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL ALARMS AND(Check ace) ALARMS AND(Check one) ❑a. AUTO PUMP SHUT OFF WHEN A LEAK OCCURS ❑a AUTO PUMP SHUT OFF WHEN A LEAK OCCURS ❑b. AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM ❑b AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM DISCONNECTION DISCONNECTION ❑c. NO AUTO PUMP SHUT OFF ❑c NO AUTO PUMP SHUT OFF ❑11. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)WITH FLOW SHUT ❑IL AUTOMATIC LEAK DETECTOR OFF OR RESTRICTION ❑I . ANNUAL INTEGRITY TEST(0.1 GPH) ❑12. ANNUAL INTEGRITY TEST(0.1 GPH) SU O SUCTION/GRAVITY SYSTEM CONTINUOUS SUMP SENSOR AUDIBLE AND VISUAL ALARMS ❑13. CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS NCY GENERATORS ONLY(Check all that apply) EMERGENCY GENERATORS ONLY(Check all dua 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 ❑15. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST) SHUT OFF OR RESTRICTION [:116.ANNUAL INTEGRITY TEST(0.1 GPH) ❑16.ANNUAL INTEGRITY TEST(0.1 GPH) ❑17. DAILY VISUAL CHECK ❑17. DAILY VISUAL CHECK VIII.DISPENSER CONTAINMENT DISPENSER CONTAINMENT ❑L 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 ❑6.NONE 469 NO VuPfu DISPENSER+AUDIBLE AND VISUAL ALARMS IX.OWNER/OPERATOR SIGNATURE I ratify that the tdonnimm provided herein ks um and ac come to the best of my knowledge SIGNATU,REOF O E PERATOR DATE 470 cq Z-07 NAME OF ER/OPRATOR(Iain[) 471 1 TITLE OF OWN TOR 472 D' rP-- umber(F me ody) 473 Peamit Approved(For tool use eery) 474 Peund Expuarbom Date(Far local we only) 471 UPCF(12/99 revised) 12 Formerly SWRCB Form B