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NIFIED PROGRAM CONSOLIDATED FORM TANKS UNDERGROUND STORAGE TANKS-TANK PAGE 2 'VI.PI GONSTRUGTIOR(CMckapIRafapply) UNDERGROUND PIPING Ill ABOVEGROUND PIPING SYSTEM TYPE ❑ 1 PRESSURE 10QL SUCTION ❑ 3. GRAVITY ❑ 1. PRESSURE ❑ 2. SUCTION ❑ 3. GRAVITY CONSTRUCTION) 1. SINGLE WALL ❑ 3. LINEDTRENCH ❑99. OTHER ❑ 1, SINGLE WALL ❑95. UNKNOVM MANUFACTURER ❑ 2. DOUBLE WALL ❑95. UNKNOWN ❑ 2. DOUBLE WALL ❑W. OTHER MANUFACTURER MANUFACTURER BARE STEEL 11e. FRPCOMPATIBLEWI100%METHANOL [31. BARE STEEL 11S. FRPCOMPATIBLEW/100%METHANOL MATERIALS AND ❑ q, STAINLESS STEEL ❑ T. GALVANIZED STEEL ❑ 2. STAINLESS STEEL 0.7. GALVANIZED STEEL CORROSION PROTECTION ❑ 3. PI kSTIC COMPATIBLE WTH CONTENTS ❑95. UNKNOVM ❑ 3. PLASTIC COMPATIBLE WITH CONTENTS ❑ S.FLEXIBLE(HOPE) ❑N OTHER 114. FIBERGLASS ❑ B. FLEXIBLE(HDPE) [199 OTHER ❑ 4. FIBERGLASS ❑ e. CATHODIC PROTECTION ❑ S. STEELW/COATING ❑ 9. CATHODIC PROTECTION ❑ 5. STEEL W1 COATING ❑95. UNKNOWN VII.PIPING LEAK DETECTION(Crack w1f if appy) UNDERGROUND PIPING ABOVEGROUND PIPING SINGLE WALL PIPINGSINGLE WALL PIPING PRESSURIZED PIPING(CMck as that apply): v0l,n06 PRESSURIZED PIPING(ClWk all Mal appy): ❑ 1. ELECTRONIC LINE LEAK DETECTOR 3.0 GPM TEST WITH AUTO PUMP SHUT OFF FOR ❑ 1, ELECTRONIC LINE LEAK DETECTOR 3.0 GPM TEST WITH AUTO PUMP SHUTOFF FOR LEAK, LEAK,SYSTEM FAILURE,AND SYSTEM DISCONNECTION+AUDIBLE AND VISUAL SYSTEM FAILURE,AND SYSTEM DISCONNECTION+AUDIBLE AND VISUAL ALARMS ALARMS ❑ 2, MONTHLY 0.2 GPM TEST ❑ 2 MONTHLY 02 GPM TEST ❑ 3. ANNUAL INTEGRITY TEST(0.1 GRH) ❑ 3. ANNUAL INTEGRITY TEST(0.1 GPM) ❑ 4, DAILY VISUAL CHECK CONVENTIONAL SUCTION SYSTEMSCONVENTIONAL SUCTION SYSTEMS(CIM*0 that appy). ❑ 5. DAILY VISUAL MONITORING OF PUMPING SYSTEM•TRIENNIAL PIPING INTEGRITY ❑ S. DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM TEST(0.1 GPM) ❑ S. 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.SELFMONITORING ❑ T. SELFMONITORING GRAVITY FLOW: GRAVITYFLOW(CM ir0 Mat appy): ❑ 9. BIENNIAL INTEGRITY TEST III t GPM) ❑ B. DAILY VISUAL MONITORING ❑ B. BIENNIAL INTEGRITY TEST(0.1 GPM) SECONDARILY CONTAINED PIPING SECONDARILY CONTAINED PIPING PRESSURIZED PIPING(Check ON Mat appy): PRESSURIZED PIPING(Check 0 Mat appy): 1D. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL ALARMS AND (Check one) 10.CONTINUOUS TURBINE BUMP SENSOR WTH AUDIBLE AND VISUAL ALARMS AND(UG eoiro) ❑ a. AUTO PUMP SHUT OFF WHEN A LEAK OCCURS ❑ e. AUTO PUMP SHOT OFF WHEN A LEAK OCCURS ❑ b ALTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM ❑ b, AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM DISCONNECTION DISCONNECTION ❑ c. NO AUTO PUMP SHUT OFF ❑ c. NO AUTO PUMP SHUT OFF ❑ 11.AUTOMATIC LINE LEAK DETECTOR(3.0 GPM TEST)WITH FLOW SHUT OFF OR ❑ 11.AUTOMATIC LEAK DETECTOR RESTRICTION ❑ 12.ANNUAL INTEGRITY TEST(0.1 GPM) ❑ 12.ANNUAL INTEGRITY TEST I0.I GPM) 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(CM*a Mat appy) EMERGENCY GENERATORS ONLY(Check art Mal apply) ❑ 14. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF•AUDIBLE AND ❑ 14. CONTINUOUS SUMP SENSOR WTHOUT AUTO PUMP SHUT OFF•AUDIBLE AND VISUAL VISUAL ALARMS ALARMS ❑ 15.AUTOMATIC LINE LEAK DETECTOR(00 GPM TEST)WTHOUT FLOW SHUT OFF OR ❑ 15. AUTOMATIC UNE LEAK DETECTOR(3.0 GPM TEST) RESTRICTION ❑ 16. ANNUAL INTEGRITY TEST 10.1 GPM) ❑ 15. ANNUAL INTEGRITY TEST(0.1 GPM) ❑ 17. DAILY VISUAL CHECK ❑ 17. DAILY VISUAL CHECK VIIL DISPENSER CONTAINMENT DISPENSER CONTAINMENT ❑ 1. FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE , ^ . .1'/ wr A ❑ 4. DAILY VISUAL CHECK DATEMSTALLED 112. CONTINUOUS DISPENSER PAN SENSOR a AUDIBLE AND VISUAL ALARMS V IVC-TRYVaa ❑ 5. TRENCH LINER/MONITORING ❑ 3. CONTINUOUS DISPENSER PAN SENSOR NTH AUTO SHUT OFF FOR DISPENSER-AUDIBLE AND VISUAL ALARMS ❑ e. NONE UL OWNEWOPERATOR SIGNATURE I tarty Inat tlro ion a and le M eM beat&my knoaMEpe. SIGNATOR T DATE NAME F E P OR(pa TITLE OF OWNERIOPERATOR Pwmk Number(wMcal u»o ay) Pamal App o (Fla lomll u»oNyl 7� Permit E»iM Dab IF rbcal use-W CLPAFORM(4199) Formerly SWRCB Form B