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UNIFIED PROGRAM CONSOLIDATED FORM TANKS ]S TANKS-TANK PAGE 2 #.AQP..)htC;CONSR(JCTiON(CheckaIItharaPFh) UNDERGROUND PIPINGS x SYSTEM TYPE ABOVEGROUND PIPING - 1. PRESSURE ❑ 2. SUCTION ❑ 3. GRAVITY x1f. PRESSURE ❑ 1. SINGLE WALL ❑ 3. LINED TRENCH ❑ 2 SUCTION ❑ 3. GRAVITY CONSTRUCTION! ❑99. OTHER ❑ 1. SINGLE WALL El 95. UNKNOWN MANUFACTURER 112. DOUBLE WALL 5. UNKN0 . DOUBLE WALL MANUFACTURER TA 1:199.OTHER MANUFACTURER . ❑ 1.BARE STEEL ❑ S. FRP COMPATIBLE W/100%METHANOL ❑ 1.BARE STEEL MATERIALS AND ❑ 2, STAINLESS STEEL ❑ 7. GALVANIZED STEEL ❑ S. FRP COMPATIBLE W/100%METHANOL CORROSION ❑ 2.STAINLESS STEEL ❑ 7.GALVANIZED STEEL ' PROTECTION ❑ 3. PLASTIC COMPATIBLE WITH CONTENTS ❑95. UNKNOWN ❑ 3.PLASTIC COMPATIBLE WITH CONTENTS ❑ 8. FLEXIBLE(HDPE) 1199. OTHER. 4 FIBERGLASS ❑ S. FLEXIBLE(HDPE) [199. OTHER W4.FIBERGLASS 135 STEEL W/COATING ❑ 9 ❑5 CATHODIC PROTECTION ❑ 9.CATHODIC PROTECTION - STEEL W/COATING 1395. UNKNOWN ,' ,:z•-,,,-r.F.�': b `' �VII�Pf!'ING EEAf(DEfECT10N{Check atl that a''� �«�" �+ '�'' > � UNDERGROUND PIPING SINGLE WALL PIPING ABOVEGROUND PIPfNG SSURIZED PIPING(Check all that apply): PRESSURIZED PIPING(Check aN that apply):SINGLE WALL PIPING _ 1. ELECTRONIC LINE LEAK DETECTOR 3.0 GPC TEST WITH AUTO PUMP SHUT OFF FOR ❑ 1. ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP SHUT OFF FOR LEAK, LEAK SYSTEM FAILURE,AND SYSTEM DISCONNECTION+AUDIBLE AND VISUAL SYSTEM FAILURE,AND SYSTEM DISCONNECTION+AUDIBLE AND VISUAL ALARMS 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 SYSTEMS: CONVENTIONAL SUCTION SYSTEMS(Check all that apply): _ ❑ S. DAILY VISUAL MONITORING OF PUMPING SYSTEM+TRIENNIAL PIPING INTEGRITY ❑ 5. DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM TEST(0.1 GPM) ❑ SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): 6.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 all that apply): ❑ 8. DAILY VISUAL MONITORING - ❑ SECONDARILY CONTAINED PIPING 9. BIENNIAL fNTEGRITY TEST(0.1 GPH) PRESSURIZED PIPING(Check all that apply): SECONDARILY CONTAINED PIPING 10. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL ALARMS AND PRESSURIZED PIPING(Checks//that apply): - C eck one) 10.CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL ALARMS AND(check one) XINa. AUTO PUMP SHUT OFF WHEN A LEAK OCCURS ❑ b.AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM ❑ a.AUTO PUMP SHUT OFF WHEN A LEAK OCCURS DISCONNECTION ❑ b.AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM DISCONNECTION ❑ c. NO AUTO PUMP SHUT OFF� El a NO AUTO PUMP SHUT OFF 11.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) ' ❑ 12.ANNUAL INTEGRITY TEST(0.7 GPM) SUCTION/GRAVITY SYSTEM: ❑ 13. CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS SUCTION/GRAVITY SYSTEM: ❑ EMERGENCY GENERATORS ONLY(Check aN that appfy� 13. CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS' - - ❑ 14. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF+ EMERGENCY GENERATORS ONLY(Check all that apply) VISUAL ALARMS AUDIBLE AND ❑ 14.CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF+AUDIBLE AND VISUAL 1115.AUTOMATIC UHUT OFF OR NE LEAK DETECTOR(3.0 GPM TEST)WITHOUT FLOW SALARMS RESTRICTION ❑ 15.AUTOMATIC LINE LEAK DETECTOR(3.0 GPM TEST) ❑ 18.ANNUAL INTEGRITY TEST(0.1 GPM) - - ❑ 17. DAILY VISUAL CHECK - - - ❑ 16.ANNUAL INTEGRITY TEST(0.1 GPM) ❑ 17 DAILY VISUAL CHECK .x a .. ;- a '`` ._ ;.0 <_:.",'•a'�.? F."`-.,'�,g. rru'�, '� � tS„ PITA4NMENT < k 777777 we,�.,.z, ,„,e. s•°a3s��. �.; DISPENSER CONTAINMENT ❑ 1. FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE DATE INSJUED0 2. CONTINUOUS DISPENSER PAN SENSOR+AUDIBLE AND VISUAL ALARMS ❑4. DAILY VISUAL CHECK ' ❑ 3.CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR DISPENSER+AUDIBLE AND VISUAL ALARMS El 8. NONE TRENCH LINER t MONITORING 1 Lenity ihIX int ation provided herein is true and accurate to the best of my knowledge. OWNER/OPERATOR SIGNATURE - SIGNAT F R DATE PERA R(pdnq I� r• Q � TITLE OF EW ERATOR Permit Number(For/Deal use only) Permit Approved(Forfoca/use only) . Pemmt Expiration Date(Forkxa!use only) :UPAFORM(4/99) Formerly SWRCB Form B