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"IFIED PROGRAM CONSOLIDATED FORTi1 <br /> TANKS <br /> UNDERGROUND STORAGE TANKS - TANK PAGE 2 <br /> VL PIPWG CONSTRUCTIONXImacralrharappy) _ <br /> UNDERGROUND PIPING ` RP A.4-Z4 ABOVEGROUND PIPING <br /> SYSTEM TYPE 111. PRESSURE �kyy�.f. SUCTION <br /> >p113. GRAVITY ❑ 1. PRESSURE ❑ Z. SUCTION ❑ 3. GRAVITY <br /> CONSTRUCTION/ 1. SINGLEWRL4 ❑.3 ❑LINEDTRENCM 99. OTHER 111. SINGLE WALL ❑95. UNKNOWN <br /> MANUFACTURER ❑ 2 DOUBLE WALL. �❑95. UNKNOWN - ❑ 2. DOUBLE WALL ❑99. OTHER <br /> MANUFACTURER <br /> pry MANUFACTURER <br /> Pr.BARE STEEL ❑ 5. FRP COMPATIBLE W/IDC%METHANOL ❑ 1. BARE STEEL ,❑.k 0 FRP COMW <br /> COMPATIBLE W/ _0%METHANOL <br /> MATERIALSAND 132. STAINLESS STEEL 117. GALVANIZED STEEL ❑ 2. STAINLESS STEEL aLJ T. GALVANIZED STEEL <br /> CORROSION <br /> PROTECTION ❑ 3. PLASTICCOMPATIBLEWTMCONTENTS 1195. UNKNOWN ❑ 3. PLASTIC COMPATIBLE WTH CONTENTS ❑ !. FLOOBLEWDREI1 ♦ ❑59 OTHER <br /> ❑ 4. FIBERGLASS ❑ S. FLEKIBLE(HDPE) 1199 OTHER ❑ 4. FIBERGLASB 119. CATHOOICSROTEQTTON <br /> ❑ 5. STEEL W/COATING ❑ 9. CATHODICPROTECTION ❑ 5. =GATING 1195. UNKNOWN ' <br /> VII.PIPING LEAK DETECTION(Choeka9MalappyJ <br /> UNDERGROUND PIPING ABOVEGROVNO PIPING <br /> SINGLE WALL PIPING SINGLE WALL PIPING <br /> PRESSURIZED PIPING(Chock a9 that eppW V LJ V,APRESSURIZED PIPING(Cteck a9 that apply): <br /> ❑ 1. ELECTRONIC LINE LEAK DETECTOR 3.0 GPM TEST WITH AUTO PUMP SHUT OFF FOR ❑ I. ELECTRONIC LINE LEAK DETECTOR 3.0 GPM TEST MTH AUTO PUMP SHUT OFF FOR LEAK, <br /> LEAK,SYSTEM FAILURE,AND SYSTEM DISCONNECTION-AUDIBLE AND VISUAL SYSTEM FAILURE,AND SYSTEM DISCONNECTION;AUDIBLE AND VISUAL ALARMS <br /> ACORNS ❑ 2. MONTHLY 02 GPM TEST <br /> ❑ 2. MONTHLY 02 GPM TEST 113. ANNUAL INTEGRITY TEST(0.1 GPM) <br /> ❑ ].ANNUAL INTEGRITY TEST(0.1 GPM) ❑ 4. DAILY WSUAL CHECK <br /> CONVENTIONAL SUCTION SYSTEMS: CONVENTIONAL SUCTION SYSTEMS(Chock all OMt apply): <br /> ❑ 5. DAILY VISUAL MONITORING Of PUMPING SYSTEM TRIENNIAL PIPING INTEGRITY ❑ 5. DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM <br /> TEST(0.1 GPM) ❑ B. TRIENNIAL INTEGRITY TEST JOA GPM) <br /> SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): <br /> ❑ 7 SELFMONITORING <br /> ❑ 7. SELF MONITORING <br /> GRAVITY FLOW: GRAVITY FLOW(Chock an Out apply) <br /> ❑ 9. BIENNIAL INTEGRITY TEST(0.1 GPM) ❑ B. DAILY VISUAL MONITORING <br /> ❑ 9. BIENNIAL INTEGRITY TEST(0.1 GPM) <br /> SECONDARILY CONTAINED PIPING SECONDARILY CONTAINED PIPING <br /> PRESSURIZED PIPING(Chock as that apply): PRESSURIZED PIPING(Check a9 that appy): <br /> 10. CONTINUOUS TURBI NE SUMP SENSOR WITH AUDIBLE AND VISUAL ALARMS AND <br /> (Check dne) 10.CONTINUOUS TURBINE SUMP SENSOR HATH AUDIBLE AND VISUAL ALARMS AND(chew one) <br /> ❑ e. AUTO PUMP SHUT OFF WHEN A LEAK OCCURS ❑ a. AUTO PUMP SHUT OFF WHEN A LEAK OCCURS <br /> ❑ E AUTO BOUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM <br /> DISCONNECTION <br /> TION 13h_ AUTO PUMP SHUT OFF FOR LEAKS.SYSTEM FAILURE AND SYSTEM DISCONNECTION <br /> DIS <br /> ❑ a NO AUTO PUMP SHUT OFF ❑ c. NO AUTO PUMP SMUT OFF <br /> ❑ 11.AUTOMATIC LINE LEAK DETECTOR(00 GPM TEST)WITH FLOW SHUT OFF OR ❑ 11.AUTOMATIC LEAK DETECTOR <br /> RESTRICTION <br /> ❑ 12.ANNUAL INTEGRITY TEST(0.1 GPM) ❑ 12.ANNUAL INTEGRITY TEST(0.1 GPM) <br /> SUCTION/GRAVITY SYSTEM: SUCTION/GRAVITY SYSTEM'. <br /> ❑ M CONTINUOUS SUMP SENSOR-AUDIBLE AND VISUAL ALARMS ❑ 13. CONTINUOUS SUMP SENSOR-AUDIBLE AND VISUAL ALARMS <br /> EMERGENCY GENERATORS ONLY(Chock 0 that appy) EMERGENCY GENERATORS ONLY(Chock a9 OW apply) <br /> ❑ 14.CONTINUOUS SUMP SENSOR WITHOOT AUTO PUMP SMUT OFF.AUDIBLE AND ❑ 14. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF a AUDIBLE AND VISUAL <br /> VISUAL ALARMS ALARMS <br /> ❑ 15.AUTOMATIC UNE LEAK DETECTOR(3.0 GPM TEST)WITHOUT FLOW SHUT OFF OR ❑ 15. AUTOMATIC LINE LEAK DETECTOR(3.0 GPM TEST) <br /> RESTRICTION <br /> ❑ 19. ANNUAL INTEGRITY TEST(0.1GPH) ❑ 16.ANNUAL INTEGRITY TEST(0 1 GPM) <br /> ❑ 17. DAILYWSUAL CHECK ❑ 17. DAILY VISUAL CHECK <br /> VRL DISPENSER CONTAINMENT <br /> DISPENSER CONTAINMENT ❑ 1. FLOAT MECHANISM THAT SHUTS OFF SMEAR VALVE v now Aj ❑ 4, WILYVISUALCMECK <br /> DAMINSTALLED IALLED ❑ 2. CONTINUOUS DISPENSER PAN SENSOR.AUDIBLE AND VISUAL ALARMS ��l ❑ S. TRENCH LINER I MONITORING <br /> yL- ❑ 3. CONTINUOUS DISPENSER PAN SENSOR WiTM AUTO SHUT OFF FOR DISPENSER-AUDIBLE AND VISUAL ALARMS ❑ e. NONE <br /> IX OWNER/OPERATOR SIGNATURE <br /> GJIIA Mat pre in on P e and e.to W tl1a heal0 toy klwwNd, <br /> SIGNATOR T DATE <br /> �3 <br /> NAME F E P OR rprintqXZL TITLE OF OWNERADPERATOR <br /> P.Numear( haulV»Choy PpmKApp WllcorrecalueeoNy) <br /> 2 / PenMl Eapira5on DN(Farbul un oNy) <br /> CUPAFORM(4/99) <br /> Formerly SWRCB Form e <br />