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%_/IFIED PROGRAM CONSOLIDATED FOS „ <br /> TANKS <br /> UNDERGROUND STORAGE TANKS - TANK PAGE 2 <br /> N.PIPING CONSTRUCTION(Check ap mat appy) <br /> UNDERGROUNO PIPING <br /> ABOVEGROUNDPIPING <br /> SYBTEM TYPE ❑ 1 PRESSURE Z. SUCTION ❑ 3. GRAVITY ❑ 1. PRESSURE ❑ 2. SUCTION <br /> ❑ 3. GRAVITY <br /> CONSTRUCTION/ ❑ 1 INGLE WALL ❑ ]. LINEA TRENCH 1:51 OTHER ❑ 1 SINGLE WALL ❑95. UNKNOWN <br /> MANUFACTURER OOUBLE WALL ❑95. UNKNOWN ❑ 2. DOUBLE WALL ❑a9, OTHER <br /> MANUFACTURER MANUFACTURER <br /> ❑ 1.BARE STEEL ❑ 8. FRP COMPATIBLE W/100%METHANOL ❑ 1, BARE STEEL ❑ S. FRP COMPATIBLE W/100%METHANOL <br /> MATERIALS AND ❑ 2 STAINLESS STEEL ❑ T. GALVANIZED STEEL ❑ 2. STAINLESS STEEL <br /> CORROSION ❑ T. GALVANIZEDSTEEL <br /> PROTECTION ❑ 3. PLASTIC COMPATIBLE WITH CONTENTS ❑95. UNKNOWN ❑ 3. PLASTIC COMPATIBLE WITH CONTENTS ❑ B. FLEKIBLE(HDPE) ❑99. OTHER <br /> ❑ 0. FIBERGLASS ❑ 8. FLEXIBLE(HOPE) ❑99. OTHER ❑ 4. FIBERGLASS ❑ B. CATHOOIC PROTECTION <br /> ❑ S. STEEL WI COATING ❑ 9. CATHODICPROTECTION 10 5. STEELW/COATING 11 S& UNKNOWN - <br /> VII.PIPING LEAK DETECTIONSINGLE (check aq flMapply) <br /> UNDERGROUND PIPING ABOVEGROUND PIPING <br /> PRESS WALL PIPING SINGLE WALL PIPING <br /> PRESSURIZED PIPING(CMck all fMMpply) PRESSURIZED PIPING(CMCF atl tMf apply): - <br /> ❑ 1. ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP SHUT OFF FOR ❑ 1. ELECTRONIC LINE LEAK DETECTOR 3.0 GPM TEST WITH 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 /> ALARMS ❑ 2. MONTHLY 02 GPM TEST <br /> 112. MONTHLY 0.2 GPH TEST <br /> ❑ <br /> ❑ 3. ANNUAL INTEGRITY TEST(0.1 GPM) 3.ANNUAL INTEGRITY TEST(0.1 GPH) <br /> ❑ e. DAILY VISUAL CHECK <br /> CONVENTIONAL SUCTION SYSTEMS. CONVENTIONAL SUCTION SYSTEMS(CMck NI May applyl: <br /> ❑ 5. DAILY VISUAL MONITORING OF PUMPING SYSTEM r TRIENNIAL PIPING INTEGRITY ❑ 5. DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM <br /> TEST to GPH) ❑ B. TRIENNIAL INTEGRITY TEST to 1 GPH) <br /> SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): <br /> ❑ T. SELF MONITORING ❑ T. SELF MONITORING <br /> GRAVITY FLOW GRAVITY FLOW(CMck aAfAaf apply): <br /> 119. BIENNIAL INTEGRITY TEST(01GPM) ❑ B. DAILY VISUAL MONITORING <br /> ❑ 9. BIENNIAL INTEGRITY TEST(0.1 GPH) <br /> SECONDARILY CONTAINED PIPING SECONDARILY CONTAINED PIPING <br /> PRESSURIZED PIPING(Clack 0 Mar apply) PRESSURIZED PIPING(CMck a0 MI appy: <br /> 10. CONTINUOUS TURBINE SUMP SENSOR VATHAUDIBLE AND VISUAL ALARMS AND <br /> (Chat.) 10.CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL ALARMS AND(Me me) <br /> ❑ a. AUTO PUMP SHUT OFF WHEN A LEAK OCCURS ❑ e. AUTO PUMP SHUT OFF WHEN A LEAK OCCURS <br /> ❑ 0 AUTDiSOPUMP ECTION OFF FOR LEAKS.SYSTEM FAILURE AND SYSTEM ❑ p. AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM DISCONNECTION <br /> DISCONNECTION <br /> ❑ c. NO AUTO PUMP SHUT OFF ❑ c NO AUTO PUMP SHUT OFF <br /> ❑ 11 AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)VATH FLOW SHUT OFF OR ❑ 11, AUTOMATIC LEAK DETECTOR <br /> RESTRICTION <br /> ❑ 12 ANNUALINTEGRITY TEST 10.1 GPH) ❑ 12.ANNUAL INTEGRITY TEST to 1 GPH) <br /> NIGRAVITY SYSTEM'. SUCTIOWGRAVITY SYSTEM <br /> 3V� : <br /> 13. CONTINUOUS SUMP SENSOR-AUDIBLE AND VISUAL ALARMS ❑ 13. CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS <br /> EMERGENCY GENERATORS ONLY(CMUWap Met apply) EMERGENCY GENERATORS ONLY(Clack ap mal apply) <br /> ❑ 14. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF.AUDIBLE AND ❑ 1a. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF.AUDIBLE AND VISUAL <br /> VISUALALARMS ALARMS <br /> ❑ 15.AUTOMATIC UNE LEAK DETECTOR(lo GPM TEST)WITHOUT FLOW SHUT OFF OR ❑ 15. AUTOMATIC LINE LEAK DETECTOR Go GPH TEST) <br /> RESTRICTION <br /> ❑ 18.ANNUAL INTEGRITY TEST(OA GPH) ❑ 18. ANNUAL INTEGRITY TEST m.I GPH) <br /> ❑ 17. DAILY VISUAL CHECK ❑ 17. DAILY VISUAL CHECK <br /> VNL DISPENSER CONTAINMENT <br /> DISPENSERCONTAINMENT ❑ i. FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE ❑ 4. DAILYWSUALCHECK <br /> DATE INSTALLED ❑ 2. CONTINUOUS DISPENSER PAN SENSOR+AUDIBLE AND VISUAL ALARMS ❑ 5. TRENCHUNER/MONITORING <br /> ❑ 3.CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR DISPENSER-AUDIBLE AND VISUAL ALARMS blibe. NONE <br /> L�wrDL OWNERIOPERATOR SIGNATURE <br /> I pe1My MN MeM <br /> 'mm.W pmriee8 am,am <br /> herein la mla arele 0 Mal aaM of my WwMa,," <br /> SIGNAT EOF ERIOPERA DATE <br /> a - - o <br /> NAME OF ONNER/OPERA1 u(w �1 TRLE OF ERK)PERATOR <br /> Papal Nanpar(Forleol use onM PemMAppMVMJ(FPrbnlo».W PamM EpkabM DMa(Forlor+l.POlyI <br /> ,7o oz <br /> CUPAFORM(4/99) Formerly SWRCB Form S <br />