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UNIFIED PROG- RAM CONSOLIDATER.,FORM <br />TANK PAGE 2 <br />UNDERGROUNDSTORAGETANKS <br />UNDFRGROUND FIPNG <br />2� Suc - 1`10V '0 3. UKAV I I Y <br />SYSTEMITYPE 541 Pkf,'S"Rr <br />A LINED TRF.*."'(111 09&). OTHER <br />MANkJFA(7n)RLK Oz. DOUBLE WAI 1. 0 Y5- UNKNOWN <br />MAW,17ACTURER <br />I nAKI.- STEEL *,M5'a tAFTHANUL [I I. HA <br />0 2. STAINLESS STEEL 0 7 GAIVANI7.ED51EEL 0 Unknnwn 07-S <br />C].I.PLASTIC COM PAT ISLE Wj1'-(.')NTFNTS 0 0 3- P <br />9 4. FFIRFRGLASS 0 g, IEXIW.r (I IDPE) 04,11 <br />❑ 5. STEEL W,COATING [] 9. CA THOJ,)IC PROTncTION 4(-A 5. ST <br />VI 1. PIPING LFAK DIRTECTION (0,�.k oil I A <br />.�±-%Zlyl (A <br />466 <br />SINGI <br />S -F WALL PIPING <br />PPESSUILIZED, PIPING ((1--k :.II <br />1, HLECTRONIC LINE (.F.AK nrimwTojt 3.0 GPM TEST WTTII AUTO rU!-I? SHUT <br />OFF FOR J..FAK, SYSTEM FAILUKE. AwnSYSTEM DISCON.NEC.TION <br />AUDIBLE AND VISUAI. ALARMS, <br />I MONTI ILY 01 GPM TESI' <br />3ANNIIAL INTL*(jPJ'I'Y TEST (0 Irwit) <br />CONVENTIONAL SUCTION SYSTEMS <br />E] S. DAILY VISUAL MONITUIUNG Of PUMPING S. <br />ySTEM -'CRIE."VAL PIPING <br />INTEGKI'I'Y TEST it) I OP11) <br />SUCTION SYSTEMS (NO VALUES IN ULLU- GROL'N5PIPIN'("): <br />SELii <br />GRAVITY FLOW <br />[]�). BIENNIALTNTF.6RITY TEST'(0.1GPM <br />W I <br />CONDARALY CO�, CATNED PIPINC; <br />PKESSUR17FT) PIPING icf.,ck all Owl VPIYI: <br />lo. coN,nNUOUS TURRINr SUMP SENSOK.Wild AL701111.17 AN't) VISUAL <br />AIARMS AND lCheck umi <br />[3a. AIM) PUMP OFF WHEN A LrAK OCCURS <br />0 b. AUTO PI IMP SI 111T OFFF(.W LEAKS, SYSTEM FAILUKE AND SYSTVAf <br />DISCUNNECTION <br />Oc. NO AUTO PUMP SHUT OFF <br />11. AUTOMATIC 1,INr LEAK Mill tc rOK (1.0 GPH TEST) wgH FLOW SHUT <br />Orr OR imsl'KIL71 ION <br />17- ANNI)A 1. INTEi(arry -i-Es r (u. I GPI 1) <br />SUC.Tf171V/r,RAVrTY %YSTENI <br />13. CONTINVOUSSUMP SENSQK+ALIDIRI.FANnVl',iUALALAR.MS <br />rMERGENCY GENk.k#,TORS ONLY 1(:kck- all tW WTV <br />E)14. CONTINUOUS SUMP ST-,N%(,)R WITHOUT' V AUTO PI. SI IkIT OFF <br />AUDIBLE AN11VISUAL ALARMS <br />EJ15, AI)TOMATI('L.INF LEAK f)ETECTOR(3.0(iPlITES'I)WIIH!211 FI -OW <br />SHUT OFF OR Rr-STR ILTION <br />C]16.AWN'LlAr.iNTrt(;RITY-i-E:ir(i),IGPH) <br />C1 17. DAILY VISUALCIIECK <br />N R'F!Z) <br />ABOV ' IC: '- IND PIPING <br />4U 0 1 PRrSSURE OZ. suc-1,10N ❑1. GRAVITY <br />460 0 I-SUNGLE WALL 0 95, UNKNOWN <br />[] 2. I)OURI .F. WALL 0 w, 0 FHER <br />-461 MANUFACTURER <br />45'� <br />462 <br />40 <br />KE STEEL, [] G. FRP COMPAT1111.17, WflfXr4 MF -MA -401. <br />'AINLFSSSIEEL 0 7. CiALV&NIZEn' STSIFL <br />ASTICCOMPAfIBLE W,C0\-T`ENTS [7j H. FLEXIBLE (HUFF) []99 OnITR <br />VERULASS 0 9. CATHODIC PROTECTION <br />EFI. W/COATIN(i 0 95, UNKNOWN ska <br />I <br />4v;ujpuQn ofte mmnoring lathe !Heal -Arlf-) <br />SINGLE WALL PIPINr <br />PRESSURIZED PJPI',(; (Check all that vtalyl' <br />01 Fl.r..CTRoNl(:I.INL-LEAK VE'rEC-Tf)R3t)(iPliTr-'qTWITIIAIJT()Pt)kll' <br />smUT Ovf VOk LEAK, SYRTEM FAILURE, A%,L) syS'mlvt DISCI NNFC-TION <br />AVDIRLE AND VISUAL ALARMS. <br />0 2 MON] MIX 0 7 GPM TEST <br />0 3. ANNUAL INTF(7.RITY TF.ST (0. IGPI 1) <br />C14 DAILY VI.S11ALCIIECK ' <br />CONYENTIONAI.- SUCTION SYSTEMS (Check all that aPPIVI <br />EI S. DAILY VISUAL %JON ITOR ING, OF PIPING AND PUMICING SYSTEM <br />06 'rRiFNNIAF.tNTr.c;RITYTEST (U.1(3PH) <br />SAFE sUCI I0N'SYSTEMS (NO VALVE% IN SELO* GKOUND PIPING)' <br />07. SELF MONIIOWNG <br />GRAVITY FL(AV (Check all Oaf apply)i <br />[IS. DAILY VISUAL MUNITOKING <br />[19. nlENNIAL INTEURITY TEST (0.1 CIP") <br />SECUr4j)pp11-V rON7AINFD PIPING <br />PRESSURIZED Pirl-NO (OmTk Al <br />10. C.ONTINIJOUS TURUINE SUMP SENSOR = At minf.r.. AND VISUAL <br />ALAIL14S AND <br />0 , AU IQ PUMP SHUT OFF WIZEN A LEAK OCCUKS <br />b AUTO pLmp SHUT OFF FOR 1,FAKS, SYSTEM I'AILURE AND SYSTEM <br />0Lrlo PUMP <br />SI JUT Orr <br />A <br />0 11. AUT(.)MATK'I.V-.AK DUALLTUR <br />0 12, ANNUAL IN'fEGWTY TEST (0.1 OPT() <br />sucn0N-'UKAvr1 Y SYSTEM <br />0 13. CONTENUOLS SUMP SENSOR - AtIT)IIII-L AND VISUAL ALARMS <br />n%1EKGEXCV (;F%rTL4TORS ONLY tCheck all ilm 3PPIV) <br />0 Ij. CONTIm-fol is SUMP SEN-KOK W11 HOUT AUTO PUMP SHUT OFF <br />AUDIBLE AND VISUAL ALARMS <br />0 15. AU10MA rIC LINE LEAK nr.TT'.r.Tr)R (3.0 GPI I TEST) <br />0 16. ANNUAL INTEGIU'l YT EST (f) I f -PI 1) <br />0 17. U.?ULY VISUAL CHECK <br />Vill. DISPEN-SERCU-1- <br />L ISPENSEKC0N'rAI\'MFNT <br />DATE INSTALLED 0 2, CONTINUUU�; I-)ISF`FNSrR PAN SENSVIJ*AUUILALF ANT)VISIIALALARMS <br />0 3 CONTINUOUS DISPENSER PAN SENSOR WTTII AL -170 SHUT OFF FOR <br />VjSpE.1;SFR - AIJT)IIILE AND %(ISI;AL Al -ARM -0 <br />IX, OWNr R/OPERATOR SIGNAXU Rk' <br />I ---tyx- the hklhttml�n plovided hucin IS wu to owbe'tormykn <br />[HATE <br />3 <br />ln't'ry "i //-, <br />7;;Wft 'Nuffftrrlrvf tical use vn1it <br />UPCF (12/99 revised) <br />M <br />p4. DAILY VISUAL CNECK <br />S. TKENCH LINLK i MONITOVONO <br />6. NONE 469 <br />k,v*I -,-IY) <br />Formerly SWRCB Form ri <br />