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"IFIED PROGRAM CONSOLIDATED FORII� TANKS UNDERGROUND STORAGE TANKS-TANK PAGE 2 VI.PIPN OCONSTRUCTWN'Mheok.IIWApply) UNDERGROUND PIPING ABOVEGROUND PIPING SYSTEM TYPE 1 PRESSURE ❑ 2. SUCTION ❑ 3. GRAVITY ❑ 1. PRESSURE ❑ 2. SUCTION ❑ 3. GRAVITY CONST�UOTION/ 1. SINGLE WALL ❑ 3. LINEDTRENCH ❑9B. OTHER ❑ t. SINGLE WALL [3 95. UNKNOWN MANUFACTURER ❑ 2 DOUBLE WALL ❑95. UNKNOWN ❑ 2. DOUBLE WALL ❑W. OTHER ' MANUFACTURER MANUFACTURER Q 1.BARE STEEL ❑ B. FRPCOMPATIBLEW110 METHANOL ❑ 1. BARE STEEL ❑ 4. FRP COMPATIBLE WI I MI METHANOL MATERIALS AND ❑ 2. STAINLESS STEEL ❑ T. GALVANIZEDSTEE� ❑ 2. STAINLESS STEEL ❑ T. GALVANIZED STEEL CORROSION ❑ PROTECTION 9. FUSTIC COMPATIBLE WITH CONTENTS 95 UNKNOWN ❑ 3. PLASTIC COMPATIBLE WITH CONTEXTS [38. FLEXIBLE(HOPE) 98.OTHER ❑ 4 FIBERGLASS ❑ 8. FLEXIBLE(HDPE) ❑99 OTHER ❑ 4 FIBERGLASS ❑ B. CATHODIC PROTECTION El 5. STEELW/COATING ❑ 9. CATHODIC PROTECTION ❑ 5. STEEL W/COATING 0 9 UNKNOWN W.PIPING LEAK DETECTION(Check a#flat appy) UNDERGROUND PIPING ABOVEGROUND PIPING SINGLE WALL PIPING SINGLE WALL PIPING PRESSURIZED PIPING(Check as that app19.. PRESSURIZED PIPING(Clack all that apply): ❑ 1. ELECTRONIC LINE LEAK DETECTOR 3.0 OFF TEST WITH AUTO PUMP SHUT OFF FOR ❑ 1. ELECTRONIC UNE LEAK DETECTOR SD 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 ALARMS ❑ 2. MONTHLY 0.2 GPH TEST ❑ 2. MONTHLY 0.2 GPM TEST ❑ 3. ANNUAL INTEGRITY TEST(DA GPH) ❑ 3. ANNUAL INTEGRITY TEST(0 1 GPH) ❑ 4. DAILY VISUAL CHECK CONVENTIONAL SUCTION SYSTEMS'. CONVENTIONAL SUCTION SYSTEMS(Clack As Mat appy): ❑ 5. DAILY VISUAL MONITORING OF PUMPING SYSTEM;TRIENNIAL PIPING INTEGRITY ❑ 5. DAILY VISUALMONITORING OF PIPING AND PUMPING SYSTEM TEST(0,1 GPH) ❑ 8. TRIENNIAL INTEGRITY TEST(0.1 GPH) SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING) SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPINI ❑ T SELFMONITORING ❑ T. SELFMONITORING GRAVITY FLOW'. GRAVITY FLOW(ChacA aI Melappty): ❑ 9. BIENNIAL INTEGRITY TEST(0.1 GPH) ❑ B. DAILY VISUAL MONITORING ❑ 9. BIENNIAL INTEGRITY TEST(01 GPH) SECONDARILY CONTAINED PIPING SECONDARILY CONTAINED PIPING PRESSURIZED PIPING(Clack as Mail applD' PRESSURIZED PIPING(Clack ala Mat appy): 10 CONTINUOUS oIM)i )US TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL 10.CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL ALARMS AND(Oack one? IDnN ❑ e. AUTO PUMP SHUT OFF WHEN A LEAK OCCURS ❑ a.AUTO PUMP SHUT OFF WHEN A LEAK OCCURS ❑ b. AUTO 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 ❑ u NO AUTO PUMP SHUT OFF ❑ 11. AUTOMATIC LINE LEAK DETECTOR(3.0 GPX TEST)WITH FLOW SHUT OFF OR ❑ 11.AUTOMATIC LEAK DETECTOR RESTRICTION ❑ 12.ANNUAL INTEGRITY TEST(0.1 GPH) ❑ 12.ANNUAL INTEGRITY TEST(0.1 GPH) SUCTIONIGRAVITY SYSTEM: SUCTION/GRAVITY SYSTEM: ❑ 13. CONTINUOUS SUMP SENSOR I AUDIBLE AND VISUAL ALARMS ❑ 13. CONTINUOUS SUMP SENSOR I AUDIBLE AND VISUAL ALARMS EMERGENCY GENERATORS ONLY(CMck ala Mat apply) EMERGENCY GENERATORS ONLY(Clack ala(hal appH ❑ 14. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF 4 AUDIBLE AND ❑ IC CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF;AUDIBLE AND VISUAL VISUALALARMS ALARMS ❑ 15 AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)WITHOUT FLOW SHUT OFF OR ❑ 15. AUTOMATIC LINE LEAK DETECTOR T3.0 GPH TEST) RESTRICTION ❑ 16. ANNUAL INTEGRITY TEST(0 1 GPH) ❑ 18 ANNUAL INTEGRITY TEST(G 1 GPH) ❑ 17. DAILYVISUAL CHECK ❑ 17. DAILY VISUAL CHECK UNI.DISPENSER CONTAINMENT DISPENSER CONTAINMENT ❑ 1 FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE ❑ 4. DAILY VISUAL CHECK DATE INSTALLED ❑ 2. CONTINUOUS DISPENSER PAN SENSOR;AUDIBLE AND VISUAL ALARMS ❑ 5. TRENCH LINER(MONITORING ❑ 3. CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR DISPENSER;AUDIBLE AND VISUAL ALARMS ❑ B. NONE IX OWNER/OPERATOR SIGNATURE I m"Mat Me inMMra9M proviGE herein is true ala aca9ma to Me MM of my M owassl . SIGNATURE OF OWNERIOPERATOR DATE NAME OF OWNER/OPERATOR(p" TITLE OF OMMEP/OPERATOR P.Nw (Far kcal uas Proy1 Penna Appn (FO,Mcal MH,0My) Parma ExpkaMn OMB(Por Nealuu-W .I CUPAFORM(4199) Formerly SWRCB Form B