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D PROGRAM CONSOLIDATED FO TANK UNDERGROUND STORAGE TANKS - TANK PAGE 2 VI.PIPING CONSTRUCTION(Chock all dwapply) PW 1 of UNDERGROUND PIPING ABOVEGROUND PIPING SYSTEM TYPE 1.PRESSURE 0 2.SUCTION [13.GRAVITY 458 ❑1.PRESSURE 0 2. SUCTION 0 3.GRAVITY 459 CONSTRUCTION [11.SINGLE WALL ❑3.LINED TRENCH 0 99.OTHER 460 ❑1.SINGLE WALL [195.UNKNOWN 462 MANUFACTURER IA 2.DOUBLE WALL 0 95.UNKNOWN ❑2.DOUBLE WALL 0 99.OTHER MANUFACTURER 461 MANUFACTURER 463 0 I.BARE STEEL 6.FRP COMPATIBLE wA6 . MErRANOL [11.BARE STEEL ❑6.FRP COMPATIBLE W/IdOx mETHANOL 0 2.STAINLESS STEEL 0 7.GALVANIZED STEEL ❑UNm0wn [12. STAINLESS STEEL 0 7.GALVANIZED STEEL [13.PLASTIC COMPATIBLE W/CONTENTS ❑99. Otha ❑3. PLASTIC COMPATIBLE W/CONTENTS ❑I.FLEXIBLE(HDPE) 0 99. OTHER [14.FIBERGLASS 0 8.FLEXIBLE(HDPE) ❑4. FIBERGLASS ❑9.CATHODIC PROTECTION ❑S.STEEL W/COATING 0 9.CATHODIC PROTECTION 464 0 5. STEEL W/COATING [195.UNKNOWN 465 VII.PIPING LEAK DETECTION C6aka11 tbat )(A dace ..fthemaitc,in iaqitoaa"he submiaW to the local UNDERGROUND PIPING ABOVEGROUND PIPING SINGLE WALL PIPING 466 SINGLE WALL PIPING 467 PRESSURIZED PIPING(Chock all that apply): PRESSURIZED PIPING(Check all that apply): ❑1.ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP SHUT ❑1. ELECTRONIC LIVE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP OFF FOR LEAK,SYSTEM FAILURE,AND SYSTEM DISCONNECTION+ SHUT OFF FOR LEAK,SYSTEM FAILURE,AND SYSTEM DISCONNECTION+ AUDIBLE AND VISUAL ALARMS. AUDIBLE AND VISUAL ALARMS. ❑2.MONTHLY 0.2 GPH TEST ❑2. MONTHLY 0.2 GPH TEST [13.ANNUAL INTEGRITY TEST(O.IGPM ❑3.ANNUAL INTEGRITY TEST(0.1GPM ❑4. DAILY VISUAL CHECK CONVENTIONAL SUCTION SYSTEMS CONVENTIONAL SUCTION SYSTEMS(Cheek all Out appy) ❑5.DAILY VISUAL MONITORING OF PUMPING SYSTEM+TRIENNIAL PIPING [15. DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM INTEGRITY TEST(0.1 GPH) SAFE SUCTION SYSTEMS(NO VALUES IN BELOW GROUNDPIPING): [16. TRIENNIAL INTEGRITY TEST(0.1 GPH) [17.SELF MONITORING SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): GRAVITY FLOW ❑7. SELF MONrrORING [19.BIENNIAL INTEGRITY TEST(0.1 GPH) GRAVITY FLOW(Check all tha appy): [18. DAILY VISUAL MONITORING ❑9. BIENNIAL INTEGRITY TEST(0.1 GPH) SECONDARILY CONTAINED PIPING SECONDARILY CONTAINED PIPING PRESSURIZED PIPING(Ouck all that apply): PRESSURIZED PIPING((Meck all Out apply): 10. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL 10. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL ll,A,..,,L,ARMS AND(Chale one) ALARMS AND(Check one) qa. 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 Cc. NO AUTO PUMP SHUT OFF Cc NO AUTO PUMP SHUT OFF 0 11. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)WITH FLOW SHUT 0 11 AUTOMATIC LEAK DETECTOR OFF OR RESTRICTION [112. ANNUAL INTEGRITY TEST(0.1 GPH) ❑12. ANNUAL INTEGRITY TEST(0.1 GPH) SUCTION/GRAVITY SYSTEM SUCTIONiGRAVrrY SYSTEM ❑13. CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS [113. CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS EMERGENCY GENERATORS ONLY(Chock all Mat apply) EMERGENCY GENERATORS ONLY(Check all Out appy) [114. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF` ❑14. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF AUDIBLE AND VISUAL ALARMS AUDIBLE AND VISUAL ALARMS ❑15. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)WITHOUT FLOW 0 15. AUTOMATIC LIVE LEAK DETECTOR(3.0 GPH TEST) SHUT OFF OR RESTRICTION 0 16.ANNUAL INTEGRITY TEST(0.1 GPH) ❑16.ANNUAL INTEGRITY TEST(0.1 GPH) 0 17. DAILY VISUAL CHECK [117. DAILY VISUAL CHECK VIII.DISPENSER CONTAINMENT DISPENSER CONTAINMENT ❑1.FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE 0 4.DAILY VISUAL CHECK DATE INSTALLED 468 02.CONTINUOUS DISPENSER PAN SENSOR+AUDIBLE AND VISUAL ALARMS ❑5.TRENCH LINER/MONITORING 0 c) 0 3.CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR 0 6.NONE 469 DISPENSER+AUDIBLE AND VISUAL ALARMS IX.OWNER/OPERATOR SIGNATURE 1ratify that the infamuion a.vidd h .u.and a<c.b Oat beat of M k ledge. S GOATOWNEROPE TOR s DATE 8/1 Q o 470 NAMEO WNER/OP TOR(prin0 TITLE OF OWNEROPERATOR 472 -I,M f4a5100 .M I COMS . cJ.a Permit Nutdaa(For local use only) 473 Permit A,pHcd(For local uae only) Pmuit Expiration Date(For local use only) 77 71 UPCF(1/99 revised) `' 175 ..of Formerly SWRCB Form B