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"IFIED PROGRAM CONSOLIDATED Fowm TANKS UNDERGROUND STORAGE TANKS -TANK PAGE 2 VL PIPIROCONSTRUCTION ICMaka9that4ppy) UNDERGROUND PIPING ABOVEGROUND PIPING SYSTEM 1 PRESSURE ❑ 2. SUCTION ❑ 3. GRAVITY ❑ 1. PRESSURE ❑ 2. SUCTION ❑ 3. GRAVITY CONSTI�ICRDHI 1. SINGLE WALL ❑ 3. UNEO TRENCH [IN OTHER ❑ 1. SINGLE WAIL ❑BS. UNKNOWN MANUFACTURER ❑ 2, DOUBLE WALL ❑95. UNKNOWN ❑ 2. DOUBLE WALL ❑N. OTHER MANUFACTURER MANUFACTURER ❑' 1.BARE STEEL ❑ B. FRP COMPATIBLE W/10094 METHANOL ❑ 1. BARE STEEL ❑ S. FRP COMPATIBLE W/10014 METHANOL MATERIALS AND ❑ 2. STAINLESS STEEL ❑ T. GALVANIZED STE ❑ 2. STAINLESS STEEL ❑ T. GALVANIZED STEEL CORROSION U PROTECTION ❑ 3. FUSTIC COMPATIBLE WITH CONTENTS 95. UNKNOWN ❑ 3. PLA3TIC COMPATIBLE HATH CONTENTS ❑ 8. FLEXIBLE(HDPE) ❑99.OTHER ❑ 4. FIBERGLASS ❑ 8. FLEXIBLE(HDPE) [IN OTHER ❑ 4. FIBERGLASS ❑ 9. CATHODIC PROTECTION ❑ 5. STEELWICOATING ❑ 9. CATHODIC PROTECTION ❑ 5 STEEL WI COATING El 95 UNKNOWN VIL PO4NO LEAK DETECTION(Clack 0 Mat appy) UNDERGROUND PIPING ABOVEGROUND PIPING SINGLE WALL PIPINGSINGLE WALL PIPING PRESSURIZED PIPING(Chack as that apply): PRESSURIZES PIPING(Clxk all that appY) ❑ 1. ELECTRONIC LINE LEAK DETECTOR 3D GPH TEST NTH AUTO PUMP SHUT OFF FOR ❑ 1. ELECTRONIC LINE LEAK DETECTOR 3D GPM 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 02 GPM TEST ❑ 2.MONTHLY 0.2 GPM TEST ❑ 3. ANNUAL INTEGRITY TEST(0.1 GPM) ❑ 3. ANNUAL INTEGRITY TEST IS.i GPH) ❑ 4. DAILY VISUAL CHECK CONVENTIONAL SUCTION SYSTEMS: CONVENTIONAL SUCTION SYSTEMS(Chack all Thal appy): ❑ 5. DAILY VISUAL MONITORING OF PUMPING SYSTEM♦TRIENNIAL PIPING INTEGRITY ❑ 5. DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM TEST(0.1 GPM) ❑ e. TRIENNIAL INTEGRITY TEST(0.1 GPM) MME SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): SAFE SUCTION SYSTEMS(NO VALVES IN SELOW GROUND PIPING). ❑ T SELF MONITORING ❑ T. SELF MONITORING GRAVITY FLOW'. GRAVITY FLOW(Clap*aN that appy): ❑ 9. BIENNIAL INTEGRITY TEST(0.1 GPM) ❑ B. DAILY VISUAL MONITORING ❑ 9. BIENNIAL INTEGRITY TEST(0.1 GPM) SECONDARILY CONTAINED PIPING SECONDARILY CONTAINED PIPING PRESSURIZED PIPING(Clack ak that appy): PRESSURIZED PIPING(Clack as that appy): 10. CONTINUOUS TURBINE SUMP SENSOR WIIH AUDIBLE AND VISUAL ALARMS AND (Clain bra) 10.CONTINUOUS TURBINE SUMP SENSOR W1TM AUDIBLE AND VISUAL AI-ARMS AND(deck oral ❑ a.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 ❑ c NO AUTO PUMP SHUT OFF ❑ 11. AUTOMATIC LINE LEAK DETECTOR(3A GPM TEST)WITH FLOW SHUT OFF OR ❑ 11,AUTOMATIC LEAK DETECTOR RESTRICTION ❑ 12. ANNUAL INTEGRITY TEST(0 1 GPM) ❑ 12. ANNUAL INTEGRITY MST R)I GPM) SUCTIONIGRAVITY SYSTEM'. SUCTIONIGRAVITY SYSTEM'. ❑ 13. CORTNUOUS SUMP SENSOR-AUDIBLE AND VISUAL ALARMS ❑ 13. CONTINUOUS SUMP SENSOR t AUDIBLE AND VISUAL ALARMS EMERGENCY GENERATORS ONLY(CM1ep*M Mat appy) EMERGENCY GENERATORS ONLY(Clack"that apply) ❑ 14. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHAT OFF AUDIBLE AND ❑ 14. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF-AUDIBLE AND VISUAL VISUALALARMS ALARMS ❑ 15. AUTOMATIC LINE LEAK DETECTOR(3.0 GPM TEST)WITHOUT FLOW SHUT OFF OR ❑ 15. AUTOMATIC LINE LEAK DETECTOR(0.0 GPM TEST) RESTRICTION ❑ 18. ANNUAL INTEGRITY TEST III GPM) ❑ 16 ANNUAL INTEGRITY TEST(0.1 GPM) ❑ 17. DAILY VISUAL CHECK ❑ 1: DAILY VISUAL CHECK VQL.DISPENSER CONTAINMENT DISPENSER CONTAINMENT ❑ 1 FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE ❑ 4 DAILY VISUAL CHECK DATEINSTALLED ❑ 2. CONTINUOUS DISPENSER PAN SENSOR-AUDIBLE AND VISUAL ALARMS ❑ 5. TRENCH LINER I MONITORING ❑ 3, CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR DISPENSER•AUDIBLE AND VISUAL ALARMS ❑ S. NONE IR.OWNERIOPERATOR SIGNATURE I mnih MM the inlarma4on p M.d retell I.aue ala..W W 8r beat of Hay kOPAla4pe. SIGNATURE OF OWNERIOPERATOR DATE NAME OF OWNERAPE TOR(pbK) TITLE OF OWNERIOPEKATOR Paa R N.t,er(Fprlocalun aJy) Palmi AppbvaJ(FPlkvlun arM7 Pam4l Eapntlort DaM(FPrkrcel uaa aft) CUPAFORM(4/99) Formerly SWRCB Form B J