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U D PROGRAM CONSOLIDATED FOR UNDERGROUND STORAGE TANKS - PRESuBMITTAL TANK VI.PIPING CONSTRUCTION(Chest all char a I) TANK PAGE z UNDERGROUND PIPING SYSTEM TYPE ®1.PRESSURE ❑2.SUCTION ABOVEGROUND PIPING Page 4 of 4 CONSTRUCTION DI-SINGLE WALL ❑3.GRAVITY 458 []1,PRESSURE ❑3.LINED TRENCH 0 99.OTHER 460 ❑2. SUCTION ❑3.GRAVITY MANUFACTURER ®2.DOUBLE WALL 0 1.SINGLE WALL 459 ❑95.UNKNOWN ❑95,UNKNOWN MANUFACTURER AQi Slpith ❑2.DOUBLE WALL 462 0 1.BARE STEEL 461 1199.OTHER ❑6.FRP COMPATIBLE w/I,, METHANOL MANUFACTURER ❑2.STAINLESS STEEL 0 7,GALVANIZED STEEL ❑I. BARE STEEL 463 0 3.PLASTIC COMPATIBLE W/CONTENTS ❑Unknown 0 2. STAINLESS STEEL ❑6.FRP COMPATIBLE 4Vll_,y METHANOL to 4.FIBERGLASS ❑S.FLEXIBLE(HDPE) 0 09. Outer f]3. PLASTIC COMPATIBLE W/CONTENTS ❑7 GALVANIZED STEEL ❑8.FLEXIBLE(HDPE) ❑99. OTHER 0 5.STEEL W/COAI'llTING ❑9.CATHODIC PROTECTION ab4 ❑4. FIBERGLASS ❑S. STEEL WICOATING ®9.CATHODIC PROTECTION VII.PIPING LEAK DETECTION(Check all char apply)(A descript on otthe monetor n ❑95.UNKNOWN UNDERGROUND PIPING g pragram shell he submitted to the tical a 465 SINGLE WALL PIPING ABOVEGROUND PIPING ) PRESSURIZED PIPING(Check all that apply). 466 SINGLE WALL PIPING 111.ELECTRONIC L ]NE LEAK DETECTOR 3.0 GPH TEST W PRESSURIZED PIPING(Check all that a 1 467 OFF FOR LEAK,SYSTEM FAILURE,AND SYSTEM DISCONNECTION P SHUT ❑1• ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP AUDIBLE AND VISUAL ALARMS. SHUT OFF FOR LE ❑2.MONTHLY 0.2 GPH TEST AUDIBLE AND VISUUAAL SYSTEM AR S ALLURE,AND SYSTEM DISCONNECTION+ ❑3•ANNUAL INTEGRITY TEST(G.IGPM 0 2. MONTHLY 0.2 GPH TEST ❑3.ANNUAL INTEGRITY TEST(0,1 GPH) CONVENTIONAL SUCTION SYSTEMS El 4. DAILY VISUAL CHECK ❑5.DAILY VISUAL MONITORING OF PUMPING SYSTEM+TRI CONVENTIONAL SUCTION SYSTEMS(Check all that INTEGRITY TEST(0,1 GPH) TRIENNIAL PIPING apply) SAFE SUCTION SYSTEMS[NO VALUES IN BELOW GROUND PIPING): 05- DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM 0 7.SELF MONITORING ❑6. TRIENNIAL INTEGRITY TEST(0.1 GPH) GRAVITY FLOW SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIpING): ❑9.BIENNIAL INTEGRITY TEST(0.1 GpH) 117. SELF MONITORING GRAVITY FLOW(Check all that apply): ❑8. DAILY VISUAL MONITORING SECONDARILY CONTAINED PIPING 0 9. BIENNIAL INTEGRITY TEST(0.1 GPM PRESSURIZED PIPING(Check all that apply). SECONDARILY CONTAINED PIPING PRESSURIZED PIPING(Check all that apply): 10. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL ALARMS AND(Check one) I D. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL ®a. AUTO PUMP SHUT OFF WHEN A LEAK OCCURS ALARMS AND(Check one) 0 b. AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM ❑a AUTO PUMP SHUT OFF WHEN A LEAK OCCURS DISCONNECTION El b AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM DISCONNECTION ❑c. NO AUTO PUMP SHUT OFF ❑c NO AUTO PUMP SHUT OFF 0 11. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)WITH FLOW SHUT OFF OR RESTRICTION 0 11. AUTOMATIC LEAK DETECTOR 0 12. ANNUAL INTEGRITY TEST(0.1 GPH) ❑12. ANNUAL INTEGRITY TEST(0.1 GPH) SUCTION/GRAVITY SYSTEM SUCTION/GRAVITY SYSTEM ❑13. CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS ❑13. CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS EMERGENCY GENERATORS ONLY(Check all that apply) EMERGENCY GENERATORS ONLY(Check all that apply) El14. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUTOFF• ❑14. CONTINUOUS SUMP SENSOR wrmou AUTO PUMP SHUTOFF AUDIBLE AND VISUAL ALARMS AUDIBLE AND VISUAL ALARMS ❑15. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST) ITW HOUT 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 GPH) ❑17. DAILY VISUAL CHECK ❑17. DAILY VISUAL CHECK V111.DISPENSER CONTAINMENT DISPENSER CONTAINMENT ❑ 1.FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE ❑4.DAILY VISUAL CHECK DATE INSTALLED 468 ID 2.CONTINUOUS DISPENSER PAN SENSOR+AUDIBLE AND VISUAL ALARMS ❑5.TRENCH LINER/MONITORING 2003 0 3.CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR [] DISPENSER+AUDIBLE AND VISUAL ALARMS b.NONE 469 IX.OWNER/OPERATOR SIGNATURE I certify that the information pmovid in, and curar !th est of my knowledge. SIGNATURE OF O P DATE 470 D.R.LEXI April 24,2003 NAME OF OWNER/OPE OR TITLE OF OWNER/OPERATOR 47, Chevron Products CompanyfD.R. LERI Retail ESH Specialist Permit Number(For local use only) 473 Permit Approved(For local use only) Permit Expiration Date(For local use only) 475 UPCF(1/99 revised) 176 Formerly SWRCS Form B