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UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANKS - TANK PAGE 2 TANKS Paw a Y(:PO4NG CONSTRUCTION(Chao so no appy UNDERGROUND PIPING __ j ABOVEGROUND PIPING SYSTEM TYPE ! PRESSURE ❑ 2. SUCTION ❑ 3. GRAVITY 458 ❑ 1. PRESSURE ❑ 2. SUCTION ❑ 3 GRAVITY 459 CONSTRUCTIOW I❑ 1. SINGLE WALL ❑ 3. LINED TRENCH ❑99. OTHER 460 ❑ 1. SINGLE WALL ❑95 UNKNOWN 452 MANUFACTURERI9 2. DOUBLE WALL 1395. UNKNOWN ❑ 2. DOUBLE WALL ❑99 OTHER MANUFACTURER A-0- S Yen lT`{ 461 - MANUFACTURER 463 �❑ 1.BARE STEEL pl 6. FRP COMPATIBLE W7100%METHANOL ❑ 1. BARE STEEL ❑ 6. FRP COMPATIBLE Wr IDo%METMANOL MATERIALS AND j❑ 2. STAINLESS STEEL ❑ T GALVANIZED STEEL ❑2. STAINLESS STEEL ❑ 7. GALVANIZED STEEL CORROSION PROTECTION ❑ 3. PLASTIC COMPATIBLE WITH CONTENTS ❑95. UNKNOWN ❑ 3. PLASTIC COMPATIBLE WITH CONTENTS ❑ 8. FLEXIBLE(HDPE) ❑99 OTHER ❑4. FIBERGLASS ❑ B. FLEXIBLE(HDPE) [399. OTHER ❑4. FIBERGLASS ❑ 9. CATHODIC PROTECTION 1❑ 5. STEEL W/COATING ❑ 9. CATHODIC PROTECTION 464 ❑ 5. STEEL Wr COATING ❑95 UNKNOWN 455 Vn.PIPING LEAK DETECTION(awar a8 Mat apply)(A rlascrmplal of On mor homy praprarn slug Le:unmase fu nu bcal awncy.) UNDERGROUND PIPING ABOVEGROUND PIPING SINGLE WALL PIPING 466 SINGLE WALL PIPING 467 PRESSURIZED PIPING(Check all Mat appty)r PRESSURIZED PIPING(C4wk a/Mat apply): ❑ 1 ELECTRONIC LINE LEAK DETECTOR 3.0 GPM TEST WITH AUTO PUMP SHUT OFF FOR ❑ 1. ELECTRONIC LINE LEAK DETECTOR 3.0 GPM 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 INTEGRrTY TEST(0.1 GPM) '❑ 4. DAILY VISUAL CHECK I CONVENTIONAL SUCTION SYSTEMS: CONVENTIONAL SUCTION SYSTEMS(Chadc M Nut appNyj: ❑ 5 DAILY VISUAL MONITORING OF PUMPING SYSTEM.TRIENNIAL PIPING INTEGRITY ❑ S. DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM TEST(0 1 GPM) ❑ 6. TRIENNIAL INTEGRITY TEST(0.1 GPM) SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING)- SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING)' ❑ 7 SELF MONITORING ❑ 7. SELF MONITORING GRAVITY FLOW. GRAVITY FLOW(Ch*all Mat appy): ❑ 9 BIENNIAL INTEGRITY TEST(0.1 GPM) ❑ 8. DAILY VISUAL MONITORING ❑ 9. BIENNIAL INTEGRITY TEST(O.1 GPM) SECONDARILY CONTAINED PIPING SECONDARILY CONTAINED PIPING PRESSURIZED PIPING(Chea N Mat appy): PRESSURIZED PIPING(CVwat all Mat apply): 10 CONTINUOUS VU TURBINE SUMP SENSOR T AUDIBLE AND VISUAL ALARMS AND 10. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL ALARMS AND(dtKk one) ❑ a. AUTO PUMP SMUT OFF V%4EN A LEAK OCCURS ❑ a. AUTO PUMP SHUT OFF WHEN A LEAK OCCURS ®b. AUTO PUMP SMUT OFF FOR LEAKS.SYSTEM FAILURE AND SYSTEM ❑b AUTO PUMP SMUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM DISCONNECTION DISCONNECTION ❑ c NO AUTO PUMP SHUT OFF I ❑ c NO AUTO PUMP SHUT OFF t 11 AUTOMATIC LINE LEAK DETECTOR(3.0 GPM TEST)WITH FLOW SHUT OFF OR ❑ 11. AUTOMATIC LEAK DETECTOR RESTRICTION ❑ 12. ANNUAL INTEGRITY TEST(0.1 GPM) ❑ 12. ANNUAL INTEGRITY TEST(0.1 GPM) SUCTION/GRAVITY SYSTEM. SUCTIOWGRAVTTY SYSTEM. ❑ 13 CONTINUOUS SUMP SENSOR-AUDIBLE AND VISUAL ALARMS ❑ 13. CONTINUOUS SUMP SENSOR.AUDIBLE AND VISUAL ALARMS EMERGENCY GENERATORS ONLY(Cheot ap Mat apply) EMERGENCY GENERATORS ONLY(Chat at Nut apply) ❑ 14 CONTINUOUS SUMP SENSOR BOUT AUTO PUMP SHUT OFF+AUDIBLE AND ❑ 14. CONTINUOUS SUMP SENSOR WTTMOyj AUTO PUMP SMUT OFF-AUDIBLE AND VISUAL VISUAL ALARMS ALARMS ❑ 15. AUTOMATIC LINE LEAK DETECTOR(3.0 GPM TEST)WTTHOUIT FLOW SHUT OFF OR ❑ 1S. AUTOMATIC LINE LEAK DETECTOR(3.0 GPM TEST) RESTRICTION ❑ 16. ANNUAL INTEGRITY TEST(0.1 GPM) I❑ 16.ANNUAL INTEGRITY TEST(0.1 GPM) ❑ 17. DAILY VISUAL CHECK li❑ 17. DALLY VISUAL CHECK VIL DISPENSER CONTARMENT DISPENSER CONTAINMENT ❑ 1. FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE ❑ 4 DAILY VISUAL CHECK I DATE INST D 468 132. CONTINUOUS DISPENSER PAN SENSOR+AUDIBLE AND VISUAL ALARMS ❑ 5. TRENCH LINER I MONrTORING l 2-0I tnn0 (tit 3. CONTINUOUS DISPENSER PAN SENSOR r1 AUTO SHUT OFF FOR DISPENSER+AUDIBLE AND VISUAL ALARMS ❑ 6. NONE 469 DL OWNERR)PERATOR S*NATURE I oar*mat the t4a wwoon provided Ara a and+carate to the best of my bwwladpa. SIGNATURE OF OWNEPUMMPATOR DATE ( N S O L 470 NAME OF OWNERIOPERATOR(pri 471 TITLE OF OWNER/OPERATOR / 472 S J I_14 C,(4 Ell / ® o e4 .kT^O r l_ Parma Number(For bawl use only) 473 Permn Approved(For k1Cal use only) 474 Penne Enpratbn Date(For tical un of y) 475 UPCF(1/99 revised) 7 Formerly SWRCB Form B