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Un1FIED PROGRAM CONSOLIDATED FO UNDERGROUND STORAGE PRESUBMITTAL TANK VI.PIPING CONSTRUCpry kaThatANKS ' TANK PAGE 2 SYSTEM TYPE UNDERGROUND PIPING ®L PRESSURE 0 2.SUCTION CONSTRUCTION 111.SINGLE WALL 3'GRgVIT}. 45e ABOVEGROUND PIPING Page 2 of 4 MANUFACTURER ❑3.LINED TRENCH ❑1.PRESSURE ®2.DOUBLE WALL WN Ogg..OTHER ❑2. SUCTION MANUFACTURER11 95'UNKNO 460 ❑1.SINGLE WALL 3•GRAVITY .�= ❑95.UNKNOWN 459 ❑I.BARE STEEL 0 6.FRP COMPATIBLE wgOp;b 0 2.DOUBLE WALL 461 ❑99.OTHER 462 ❑2 STAINLESS STEEL METHgNOI MANUFACTURER ❑3.PLASTIC COMPATIBLE/CONTVEN�'TS ED STEEL ❑1'BARE STEEL UoWO ❑2. STAINLESS STEEL 6.FRP COMPATIBLE wrap% 463 ®4.FIBERGLASS ❑99. Other 0 3. PLASTIC COMPATIBLE W/CONTENTS IMTN^NOL ❑S.STEEL W/COATING O 8.FLEXIBLE(HDPE) ❑7.GALVANIZED STEEL ❑9.CATHODIC PROTECTION 04. FIBERGLASS ❑8.FLEXIBLE(HDPE) O 99. OTHER VII•PIPING LEAK DETE 464 ❑5. STEEL W/COATING 0 9.CATHODIC PROTECTION UNDERGROUND PIPING CTI (Chek all Net apply)(A d111 prion ofthe mmdmdn 0 95'UNKNOWN SINGLE WALL PIPING g pro8ratn shall"submitted to the IoW 465 PRESSURIZED PIPING 466 ABOVEGRO a8ency.) (chant K war apply). SINGLE WALL PIPING ❑1.ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST W ALL PIPING OFF FOR LEAK,SYS URE qND r�f1t AUTO PUMPS PRESSURIZED PIPING(Check all that apply): AND VISUAL FAIL SYSTEM DTSCONNECTION+ HUT 0 L ELECTRONIC LINE L a67 AUDIBLE ALARMS. LEAK DETECTOR ❑2.MONTHLY 0.2 GPH TEST SHUT LEF FOR LEAK,SYSTEM FAILURE,GAND PH SYSTEM DISCONNET WITH AUTO CTION+ AUDIBLE AND VISUAL ALARMS. ❑3.ANNUAL INTEGRITY TEST(O.IGPfO ❑2. MONTHLY 0.2 GPH TEST ❑3.ANNUAL INTEGRITY TEST(0.IGPH) CONVENTIONAL SUCTION SYSTEMS ❑4. DAILY VISUAL CHECK ❑5.DAILY VISUAL MONITORING OF PUMPING SYSTEM+TRI CONVENTIONAL SUCTION SYSTEMS(Check all that apply) INTEGRITY TEST(0.1 GPH) TRIENNIAL PIPING SAFE SUCTION SYSTEMS 5. DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM (NO VALUES M BELOW GROUND PIPING} ❑7.SELF MONITORING ❑6. TRIENNIAL INTEGRITY TEST(0.1 GPH) GRAVITYFLOW SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING); 9.BOMNIAL INTEGRITY TEST(0,I GPH) ❑7. SELF MONITORING GRAVITY FLOW(Check all that apply): ❑8. DAILY VISUAL MONITORING SECONDARILY CONTAINED PIPING ❑9. BIENNIAL INTEGRITY TEST(0.1 GPH) PRESSURIZED PIPING(C ack all that eppIA SECONDARILY CONTAINED PIPING 10. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL PRESSURIZED PIPING(Check all that apply): ALARMS AND(Chet ate) 10. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL ®L AUTO PUMP SHUT OFF WHEN A LEAK OCCURS FARMS AND(Chek one) ®b. AUTO PUMP SHUT OFF FOR1-PARS ❑a AUTO PUMP SHUT OFF WHEN A LEAK OCCURS DISCONNECTION TEM SYSTP]Q FAILURE AND SYSTEM 0 b AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM Oc NO AUTO PUMP SHUT OFF DISCONNECTION Elc NO AUTO PUMP SHUT OFF ®ll. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)WITH FLOW SHUT OFF OR RESTRICTION ❑11. AUTOMATIC LEAK DETECTOR ❑12. ANNUAL INTEGRITY TEST(0.1 GPIO 0 12. ANNUAL INTEGRITY TEST(0.1 GPH) SUCTION/GRAVITY SYSTEM SUCTION/GRAVITY SYSTEM 013. CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS 013. CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS EMERGENCY GENERATORS ONLY(Chack all that apply) EMERGENCY GENERATORS ONLY(Chek all that apply) 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 [115. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST) (]I6.ANNUAL INTEGRITY TEST(O,I GPH) 0 16.ANNUAL INTEGRITY TEST(0.1 GPH) ❑ 17. DAILY VISUAL CHECK 0 17. DAILY VISUAL CHECK VIII.DISPENSER CONTAINMENT DISPENSER CONTAINMENT O 1.FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE 0 4.DAILY VISUAL CHECK DATE INSTALLED 468 ®2.CONTINUOUS DISPENSER PAN SENSOR+AUDIBLE AND VISUAL ALARMS 0 5.TRENCH LINER/MONITORING 2002 ®3.CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR DISPENSER+AUDIBLE AND VISUAL ALARMS 0 6.NONE 469 IX.OWNER/OPERATOR SIGNATURE 1 corny the she informe6on Previded herein is true and accurate to the best ofmy knowledge. SIGNATURE OF OWNER/OPER I.OR DATE D,R, LERI 4116102 470 NAME OF OWNER/OPERATOR(plint) TITLE OF OWNERIOPERATOR 477. Chevron Products Company/D.R.LERI Retail ESH Specialist Permit Number For local use only) 473 Pennil Approvcd(For local useonly) Pamit Expiration Date(For local use only) 475 UPCF(1199 revised) 174 Formerly SWRCs Form s