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IFIED PROGRAM CONSOLIDATED FO- I `-..a, TANK UNDERGROUND STORAGE TANKS - TANK PAGE 2 V1.PIPING CONSTRUCTION(Check an mat appy) Page 6 of 8 UNDERGROUND PIPING ABOVEGROUND PIPING SYSTEM TYPE ®1.PRESSURE O 2.SUCTION O 3.GRAVITY 458 O I.PRESSURE [12. SUCTION O 3.GRAVITY 459 CONSTRUCTION ®1.SINGLE WALL ®3.LINED TRENCH O 99.OTHER 460 O 1.SINGLE WALL O 95.UNKNOWN 462 MANUFACTURER O 2.DOUBLE WALL O 95.UNKNOWN O 2.DOUBLE WALL O 99.OTHER MANUFACTURER AO Smith 461 MANUFACTURER 463 O 1.BARE STEEL O 6.FRP COMPATIBLE w/I W% METRANOL O 1.BARE STEEL O 6.FRP COMPATIBLE W/loo%METHANOL O 2.STAINLESS STEEL O 7.GALVANIZED STEEL O Unknown O 2. STAINLESS STEEL O 7.GALVANIZED STEEL O 3.PLASTIC COMPATIBLE W/CONTENTS O 99. Other O 3. PLASTIC COMPATIBLE W/CONTENTS O 8.FLEXIBLE(HDPE) O 99. OTHER ®4.FIBERGLASS O 8.FLEXIBLE(HDPE) O 4. FIBERGLASS O 9.CATHODIC PROTECTION O 5.STEEL W/COATING ®9.CATHODIC PROTECTION 464 O 5. STEEL W/COATING [195.UNKNOWN 465 VII.PIPING LEAK DETECTION(check all that (A ddcriptbn ofthe monhoring pealparn alW1 be submitted w the beat eac . UNDERGROUND PIPING ABOVEGROUND PIPING SINGLE WALL PIPING 466 SINGLE WALL PIPING 467 PRESSURIZED PIPING(Check all mat apply): PRESSURIZED PIPING(check all that appy): ®1.ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WIT B AUTO PUMP SHUT O 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 [12. MONTHLY 0.2 GPH TEST ®3.ANNUAL INTEGRITY TEST(O.IGPH) [13.ANNUAL INTEGRITY TEST(OAGPI) O4. DAILY VISUAL CHECK CONVENTIONAL SUCTION SYSTEMS CONVENTIONAL SUCTION SYSTEMS(Check all mat appy) O S.DAILY VISUAL MONITORING OF PUMPING SYSTEM+TRIENNIAL PIPING O S. DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM INTEGRITY TEST(0.1 GPH) SAFE SUCTION SYSTEMS(NO VALUES IN BELOW GROUND PIPING): O 6. TRIENNIAL INTEGRITY TEST(0.1 GPH) O 7.SELF MONITORING SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): GRAVITY FLOW O 7. SELF MONITORING O 9.BIENNIAL INTEGRITY TEST(0.1 GPH) GRAVITY FLOW(Check all 0w appy): O 8. DAILY VISUAL MONITORING O 9. BIENNIAL INTEGRITY TEST(0.1 GPH) SECONDARILY CONTAINED PIPING SECONDARILY CONTAINED PIPING PRESSURIZED PIPING(Check all that appy): PRESSURIZED PIPING(Check all that appy): 10. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL 10. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL ALARMS AND(Check oM) ALARMS AND(Check one) O a. AUTO PUMP SHUT OFF WHEN A LEAK OCCURS O a AUTO PUMP SHUT OFF WHEN A LEAK OCCURS O b. AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM O b AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM DISCONNECTION DISCONNECTION Oc. NO AUTO PUMP SHUT OFF Oc NO AUTO PUMP SHUT OFF O H. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)WITH FLOW SHUT OFF OR RESTRICTION ❑11. AUTOMATIC LEAK DETECTOR [112. ANNUAL INTEGRITY TEST(0.1 GPH) [112. ANNUAL INTEGRITY TEST(0.1 GPH) SUCTION/GRAVITY SYSTEM SUCTION/GRAVITY SYSTEM O 13. CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS ❑13. CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS EMERGENCY GENERATORS ONLY(Check A that appy) EMERGENCY GENERATORS ONLY(Check all that apply) [114. CONTINUOUS SUMP SENSOR WITH0117 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)WITHO FLOW O SHUT OFF OR RESTRICTION 15. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST) O 16.ANNUAL INTEGRITY TEST(0.1 GPH) O 16.ANNUAL INTEGRITY TEST(0.1 GPH) 017. DAILY VISUAL CHECK 017. DAILY VISUAL CHECK VIII.DISPENSER CONTAINMENT DISPENSER CONTAINMENT O L FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE O 4.DAILY VISUAL CHECK DATE INSTALLED 468 O 2.CONTINUOUS DISPENSER PAN SENSOR+AUDIBLE AND VISUAL ALARMS ®5.TRENCH LINER/MONITORING O 3.CONTINUOUS DISPENSER PAN SENSOR WIT I AUTO SHUT OFF FOR DISPENSER+AUDIBLE AND VISUAL ALARMS ❑6.NONE 469 D(.OWNER/OPERATOR SIGNATURE l unit'dm the infomut' vidN a tothebW.fw,knc-Wge. SIGNATURE OF _ O DATE 470 /D.R,LER/ ' 10/29/02 NAMEOFOWN O m) TITLE OF OWNER/OPERATOR 472 Chevron Products Company/D.RLERI Retail ESH Specialist Pemut Number(For local we only) 473 Pe AW.,cl(Foe local uae only) Pa h EVkaion Date(Foe local use only) 475 UPCF(1/99 revised) 178 .-a" Formerly SWRCB Form B