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AL UNIFIED PROGRAM CONSOLIDATED FOPM PRESUBMITTAL TANK UNDERGROUND STORAGE TANKS - TANK PAGE 2 VI.PIPING CONSTRUCTION(Check all that apply) Page 4 of 0 UNDERGROUND PIPING ABOVEGROUND PIPING SYSTEM TYPE ®1,PRESSURE 0 2.SUCTION ❑3.GRAVITY 458 ❑1.PRESSURE 2. SUCTION 3.GRAVITY 459 CONSTRUCTION C L SINGLE WALL 3.LINED TRENCH 99.OTHEA 460 1.SINGLE WALL MANUFACTURER ®2.DOUBLE WALL ❑95.UNKNOWN q62 ❑95.UNKNOWN ❑2.DOUBLE WALL 0 99.OTHER MANUFACTURER AO Smith 461 MANUFACTURER 463 ❑ I.BARE STEEL 0 6.FRP COMPATIBLE w/I0o% METHANOL 1.BARE STEEL ❑2.STAINLESS STEEL 7.GALVANIZED STEEL Uldmown ❑6.FRP COMPATIBLE W/I90%METHANOL ❑3.PLASTIC COMPATIBLE W/CONTENTS ❑2. STAINLESS STEEL ❑7.GALVANIZED STEEL ❑99. Other 3. PLASTIC COMPATIBLE W/CONTENTS 8.FLEXIBLE(HDPE) 99. OTHER ®4.FIBERGLASS 8.FLEXIBLE(HDPE) 4. FIBERGLASS ❑5.STEEL W/COATING ❑9.CATHODIC PROTECTION a64 ❑9.CATHODIC PROTECTION ❑5. STEEL W/COATING 95.UNKNOWN q65 VII.PIPING LEAK DETECTION(check all mat apply)(A deacriplion ofine monitoring program shall be aubmined to the local egenryJ UNDERGROUND PIPING ABOVEGROUND PIPING SINGLE WALL PIPING 466 SINGLE WALL PIPING 467 PRESSURIZED PIPING(Check all mat apply): PRESSURIZED PIPING(Check all that apply): C 1.ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP SHUT 0 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 C]2. MONTHLY 0.2 GPH TEST ❑3.ANNUAL INTEGRITY TEST(OAGPH) ❑3.ANNUAL INTEGRITY TEST(O.1GPH) ❑4. DAILY VISUAL CHECK CONVENTIONAL SUCTION SYSTEMS CONVENTIONAL SUCTION SYSTEMS(Check all that apply) ❑S.DAILY VISUAL INTEGRITY TEST(0.1 GPH)MONITORING OF PUMPING SYSTEM+TRIENNIAL PIPING C 5. DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM SAFE SUCTION SYSTEMS(NO VALUES IN BELOW GROUND PIPING): C 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(Check all that apply): ❑8. DAILY VISUAL MONITORING ❑9. BIENNIAL INTEGRITY TEST(0.1 GPH) SECONDARILY CONTAINED PIPING SECONDARILY CONTAINED PIPING PRESSURIZED PIPING(Check all matapply): PRESSURIZED PIPING(Check all that apply); 10. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL 10. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL ALARMS AND(Check one) ALARMS AND(Check one) On. AUTO PUMP SHUT OFF WHEN A LEAK OCCURS 0 a AUTO PUMP SHUT OFF WHEN A LEAK OCCURS ®It. AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM ❑b AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM DISCONNECTION DISCONNECTION Cc. NO AUTO PUMP SHUT OFF Cc NO AUTO PUMP SHUT OFF ®11. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)WITH FLOW SHUT OFF OR RESTRICTION ❑11. AUTOMATIC LEAK DETECTOR C 12. ANNUAL INTEGRITY TEST(0.1 GPH) C 12. ANNUAL INTEGRITY TEST(0.1 GPH) SUCTION/GRAVITY SYSTEM SUCTION/GRAVITY SYSTEM C 13. CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS 013. CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS EMERGENCY GENERATORS ONLY(Check all that apply) EMERGENCY GENERATORS ONLY(Check all that apply) 0 14. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF0 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 GPH) C 17. DAILY VISUAL CHECK C 17. DAILY VISUAL CHECK VIII.DISPENSER CONTAINMENT DISPENSER CONTAINMENT O L FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE 0 4.DAILY VISUAL CHECK DATE INSTALLED 468 ®2.CONTINUOUS DISPENSER PAN SENSOR+AUDIBLE AND VISUAL ALARMS ❑5.TRENCH LINER/MONITORING 2002 ®3.CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR DISPENSER+AUDIBLE AND VISUAL ALARMS ❑6.NONE 469 IX.OWNER/OPERATOR SIGNATURE 1 certify that the information provided herein is true and accurate to the bect of my knowladge. SIGNATURE OF OWNER/OPERATOR DATE 470 D.R. LERI 4/16/02 NAME OF OWNER/OPERATOR(print) TITLE OF OWNER/OPERATOR 472 Chevron Products Company/D.R. LERI Retail ESH Specialist Pcnnit Number(Fm local me only; 473 Permit Approved(For local use only) Permit Expiration Date For local use only) 475 UPCF(1/99 revised) 176 Formerly SWRCB Form B