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lb,dFIED PROGRAM CONSOLIDATED FO ;TANK UNDERGROUND STORAGE TANKS - TANK PAGE 2VI.PIPING CONSTRUCTION(Chock all that I) z of a UNDERGROUND PIPING ABOVEGROUND PIPINGSYSTEM TYPE ®1.PRESSURE ❑2.SUCTION ❑3.GRAVITY 458 ❑1.PRESSURE 0 2. SUCTION ❑3.GRAVITY459 CONSTRUCTION ®1.SINGLE WALL ®3.LINED TRENCH ❑99.OTHER 460 ❑1.SINGLE WALL ❑95.UNKNOWN 462 MANUFACTURER ❑2.DOUBLE WALL ❑95.UNKNOWN ❑2.DOUBLE WALL ❑99.OTHER MANUFACTURER AO Smith a61 MANUFACTURER_ 463 ❑I.BARE STEEL ❑6.FRP COMPATIBLE w/IM METHANOL ❑1.BARE STEEL ❑6.FRP COMPATIBLE W/I0 METHANOL ❑2.STAINLESS STEEL ❑7.GALVANIZED STEEL I[]Unkvown ❑2. STAINLESS STEEL ❑7.GALVANIZED STEEL ❑3.PLASTIC COMPATIBLE W/CONTENTS ❑99. OtbeT ❑3. PLASTIC COMPATIBLE W/CONTENTS ❑8.FLEXIBLE(HDPE) O 99. OTHER ®4.FIBERGLASS ❑1.FLEXIBLE(HOPE) 0 4. FIBERGLASS ❑9.CATHODIC PROTECTION ❑5.STEEL W/COATING ®9.CATHODIC PROTECTION 464 ❑5. STEEL W/COATING ❑95.UNKNOWN 465 VII.PIPING LEAK DETECTION Chock all that apply)(A do ion ofthe had,$prlpaar.hall be submittd w the kcal agcn .) UNDERGROUND PIPING ABOVEGROUND PIPING SINGLE WALL PIPING 466 SINGLE WALL PIPING 467 PRESSURIZED PIPING(Chock all that appy)'. PRESSURIZED PIPING(Check all that apply): ®1.ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP SHUT ❑L ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO DISCONNECTION OFF FOR LEAK,SYSTEM FAILURE,AND SYSTEM DISCONNECTION+ SHUT OFF FOR LEAK,SYSTEM FAILURE,AND SYSTEM DISCONNF.CT/ON+ AUDIBLE AND VISUAL ALARMS. AUDIBLE AND VISUAL ALARMS. ®2.MONTHLY 0.2 GPH TEST ❑2. MONTHLY 0.2 GPH TEST ®3.ANNUAL INTEGRITY TEST(O.1GPM ❑3.ANNUAL INTEGRITY TEST(O.IGPM ❑4. DAILY VISUAL CHECK CONVENTIONAL SUCTION SYSTEMS CONVENTIONAL SUCTION SYSTEMS(Check all that apply) ❑5.DAILY VISUAL MONITORING OF PUMPING SYSTEM+TRIENNIAL PIPING 0 S. DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM INTEGRITY TEST(0.1 GPM SAFE SUCTION SYSTEMS(NO VALUES IN BELOW GROUND PIPING): ❑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(Chock all that apply): ❑8. DAILY VISUAL MONITORING ❑9. BIENNIAL INTEGRITY TEST(0.1 GPH) SECONDARILY CONTAINED PIPING SECONDARILY CONTAINED PIPING PRESSURIZED PIPING(Chock all thin appy): PRESSURIZED PIPING(Check all tam apply): 10. CONTINUOUS TURBINE SOW SENSOR WITH AUDIBLE AND VISUAL 10. CONTINUOUS TURBINE SUMP SENSOR WITH ADDIBLE AND VISUAL ALARMS AND(Chock.) ALARMS AND(Check ono) ❑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 Dc. NO AUTO PUMP SHUT OFF Oc NO AUTO PUMP SHUT OFF ❑11. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)WITH FLOW SHUT OFF OR RESTRICTION ❑11. AUTOMATIC LEAK DETECTOR [112. ANNUAL INTEGRITY TEST(0.1 GPM ❑12. ANNUAL INTEGRITY TEST(0.1 GPH) SUCTION/GRAVITY SYSTEM SUCTION/GRAVITY SYSTEM ❑13. CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS 013. CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS EMERGENCY GENERATORS ONLY(Check an that apply) EMERGENCY GENERATORS ONLY(Check all that appy) ❑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 SHUT OFF OR RESTRICTION 15. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST) ❑16.ANNUAL INTEGRITY TEST(0.1 GPH) ❑16.ANNUAL INTEGRITY TEST(0.1 GPID ❑17. DAILY VISUAL CHECK [117. DAILY VISUAL CHECK VIII.DISPENSER CONTAINMENT DISPENSER CONTAINMENT ❑1.FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE ❑4.DAILY VISUAL CHECK DATE INSTALLED 469 [12.CONTINUOUS DISPENSER PAN SENSOR+AUDIBLE AND VISUAL ALARMS ®5.TRENCH LINER/MONITORING 3.CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR DISPENSER+AUDIBLE AND VISUAL ALARMS ❑6.NONE 46n IX.OWNER/OPERATOR SIGNATURE I mtiy tlut the information prov' truc and aocumte to the beat of my knowledge. SIGNATURE OF PE OR DATE 470 DX LEWJ 10/29./02 NAME OF OWNER/OPERATOR(Int) TITLE OF OWNER/OPERATOR 472 Chevron Products Company/D.R. LERI Retail ESH Specialist Pcrmit Number(For local use only) 473 Pemut Approved(Far local use only) Penmt Expiration Date(Far local use only) 475 UPCF(1/99 revised) 174 %.01 Formerly SWRCB Form B