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WTIED PROGRAM CONSOLIDATED FO• b eve J TANKS UNDERGROUNDS TORAGE TANKS - TANK PAGE 4 !B Pae. VI.PIPING CONSTRUCTION(Check all 1h t apply) UNDERGROUND PIPING ABOVEGROUND PIPING SYSTEM TYPE % 1. PRESSURE ❑ 2. SUCTION ❑ 3. GRAVITY ❑ 1. PRESSURE ❑ 2. SUCTION ❑ 3. GRAVITY CONSTRUCTION/ 1. SINGLE WALL ❑ 3. LINEO TRENCH ❑99. OTHER ❑ 1. SINGLE WALL ❑95. UNKNOWN MANUFACTURIIR Da. DOUBLE WAL NKNOWN ❑ 2. DOUBLE WALL 1199. OTHER MANUFACTURER Western FitoergI.D ll MANUFACTURER ❑ 1.BARESTEEL . FRP COMPATIBLE W/100%METHANOL ❑ 1. BARE STEEL ❑ 6. FRP COMPATIBLE W/100%.METHANOL MATERIALS AND ❑ 2, STAINLESS STEEL ❑ 7. GALVANIZED STEEL ❑ 2. STAINLESS STEEL ❑ T. GALVANIZED STEEL CORROSION PROTECTION El3. PLASTICCOMPAT�BLE ITHCONTENTS 1195.5. UNKNOWN 133. PLASTIC COMPATIBLE WITH CONTENTS 138. FUMBLE(HOPE) El N. OTHER ❑ 4. FIBERGLASS FLEXIBLE(HOPE) El de. OTHER ❑ 4. FIBERGLASS ❑ 9. CATHODIC PROTECTION ❑ 5. STEEL W/COATING 9. CATHODIC PROTECTION ❑ 5. STEELWICOATING ❑95. UNKNOWN VII.PIPING LEAK DETECTION(Check all that appy) UNDERGROUND PIPING ABOVEGROUND PIPING SINGLE WALL PIPING SINGLE WALL PIPING P SSURIZED PIPING(Check all that apply): PRESSURIZED PIPING(Check all Mat apply): bLECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP SHUT OFF FOR ❑ 1. ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP SHUT OFF FOR LEAK, LEAK,SYSTEM FAILURE,AND SYSTEM DISCONNECTION+AUDIBLE AND VISUAL SYSTEM FAILURE,AND SYSTEM DISCONNECTION+AUDIBLE AND VISUAL ALARMS {grL_ARMS ❑ 2. MONTHLY 0.2 GPH TEST 1 21 MONTHLY 0.2 GPH TEST ❑ 3. ANNUAL INTEGRITY TEST(0.1 GPH) ❑ 3. ANNUAL INTEGRITY TEST(04 GPH) ❑ 4. DAILY VISUAL CHECK CONVENTIONAL SUCTION SYSTEMS: CONVENTIONAL SUCTION SYSTEMS(Check all Oral apply): ❑ 5. DAILY VISUAL MONITORING OF PUMPING SYSTEM+TRIENNIAL PIPING INTEGRITY ❑ 5. DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM TEST(0.1 GPH) ❑ B. TRIENNIAL INTEGRITY TEST(0.1 GPH) SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING)', ❑ T. SELF MONITORING ❑ 7. SELF MONITORING GRAVITY FLOW: GRAVITY FLOW(Check all that appy): ❑ 9. BIENNIAL INTEGRITY TEST(0.1 GPH) ❑ 8. DAILYVISUAL MONITORING ❑ 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 ALARMS AND 10.CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL ALARMS AND(check one) Check one) a. AUTO PUMP SHIT OFF WHEN A LEAK OCCURS ❑ a. AUTO PUMP SHUT OFF WHEN A LEAK OCCURS . AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM DISCONNECTION ❑ D. AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM DISCONNECTION C. NO AUTO PUMP SHUT OFF ❑ c. NO AUTO PUMP SHUT OFF kX 1. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)WITH FLOW SHUT OFF OR ❑ 11. AUTOMATIC LEAK DETECTOR RESTRICTION 12. ANNUAL INTEGRITY TEST(0.1 GPH) ❑ 12. ANNUAL INTEGRITY TEST(01 GPH) SUCTIOWGRAVITY SYSTEM: SUCTIOWGRAVITYSYSTEM: ❑ 13. CONTINUOUS SUMP SENSOR-AUDIBLE AND VISUAL ALARMS ❑ 13. CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS EMERGENCY GENERATORS ONLY(Check all Nat apply) EMERGENCY GENERATORS ONLY(Check all Nat appy) ❑ 14. CONTINUOUS SUMP SENSOR WITHO AUTO PUMP SHUT OFF+AUDIBLE AND ❑ 14. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF.AUDIBLE AND VISUAL VISUAL ALARMS ALARMS ❑ 15. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)WITHOUT FLOW SHUT OFF OR ❑ 15. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST) RESTRICTION ❑ 16. ANNUAL INTEGRITY TEST(0.1 GPH) ❑ 16.ANNUAL INTEGRITY TEST(0.1 GPH) ❑ 17. DAILYVISUALCHECK ❑ 17, DAILY VISUAL CHECK VIII,DISPENSER CONTAINMENT DISPENSER CONTAINMENT ❑ 1. FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE ❑ 4. DAILY VISUAL CHECK / NSTALLED I 2. CONTINUOUS DISPENSER PAN SENSOR+AUDIBLE AND VISUAL ALARMS ❑ 5, TRENCH LINER/MONITORING 2001 V . COMINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR DISPENSER+AUDIBLE AND VISUAL AIARMS ❑ 6. NONE IX.OWNER/OPERATOR SIGNATURE I certify tet the Information onwde M1 11tole and acrale to the best of my knorvletl9e. SIGNATURE OF OWNEWOPERATO DATE Ootobar 25,2W7 NAME OF OW NETUOPERATOR(Wino TITLE OF OWNER/OPERATOR Butch Hobson Safety and Environmental Af(aim Manager Permit Number(For local use only) Penult Approved(For local use only) Permit Expiration Date red,local use only) CUPAFORM(4/99) Formerly SW RCB Form B