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UPP ED PROGRAM CONSOLIDATED FOIV TANKS UNDERGROUND STORAGE TANKS - TANK PAGE 2 VL PIPING CONSTRUCTION(Check all that apply) gage Iz of t3 UNDERGROUND PIPING ABOVEGROUND PIPING SYSTEM TYPE ❑ 1.PRESSURE ❑2.SUCTION ❑ 3.GRAVITY 458 ❑ 1.PRESSURE ❑ 2.SUCTION ❑ 3.GRAVITY 459 CONSTRUCTION ❑ 1.SINGLE WALL ❑ 3.LINED TRENCH ❑99.OTHER ❑ 1.SINGLE WALL ❑ 95.UNKNOWN 462 ❑ 2.DOUBLE WALL ❑95.UNKNOWN ❑2.DOUBLE WALL El99.OTHER 463 461 MANUFACTURER MANUFACTURER ❑ 1.BARE STEEL ❑ 6.FRP COMPATIBLE w/1p^METHANOL ❑ 1.BARE STEEL ❑ 6.FBI,COMPATIBLE w/l00/METHANOL ❑2.STAINLESS SITE ❑ 7.GALVANIZED STEEL ❑2.STAINLESS SITE ❑ 7.GALVANIZED STEEL ❑PLASTIC COMPATIBLE W/CONTENTS ❑ 95.UNKNOWN ❑PLASTIC COMPATIBLE W/CONTENTS ❑95.UNKNOWN ❑4.FIBERGLASS ❑ S.FLEXIBLE(HDPE) ❑ 99.OTHER 0 4.FIBERGLASS El 8.aha XIBLE PE) TIO ❑99.OTHER El 5.STEEL W/COATING ❑9.CATHODIC PROTECTION El 5.STEEL W OATING [19. 465 VII.PIPING LEAK DETECTION(Check ag that apply)(A description ofthe monitoring program shall be subrmtted to the local agencyI UNDERGR-QUND PIPING ABOVEGROUND PIPING SINGLE WALL PIPING 466 SINGLE WALL PIPING 467 PRESSURIZED PIPING(Check all that appal): PRESSURIZED PIPING(Chock all that apply): ❑ 1.ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WIT AUTO PUMP ❑ 1.ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP SHUT 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 ❑ 3.ANNUAL INTEGRITY TEST(0.1 GPH) ❑3.ANNUAL INTEGRITY TEST(0.1 GPH) ❑4.DAILY VISUAL CHECK CONVENTIONAL SUCTION SYSTEMS(Check all that apply) CONVENTIONAL SUCTION SYSTEMS El 5.DAILY VISUAL MONITORING OF PUMPING SYSTEM+TRIENNIEAL ❑ 5.DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM PIPING INTEGRITY TEST(0.1 GPH) ❑6.TRIENNIAL INTEGRITY TEST(0.1 GPH) SAFE SUCTION SYSTEMS(NO VALUES IN BELOW GROUNDPIPING): SAFE SUCTION SYSTEMS(NO VALUES IN BELOW GROUNDPIPING): [-17.SELF MONITORING ❑ 7.SELF MONITORING GRAVITY FLOW ❑9.BIENNIAL INTEGRITY TEST(0.1)GPH GRAVITY FLOW(Chock dl that apply): ❑ S.DAILY VISUAL MONITORING ❑ 9.BIENNIAL INTEGRITY TEST(0.1)GPH SECONDARILY CONTAINED PIPING SECONDARILY CONTAINED PIPING PRESSURIZED PIPING(Check au that apply): PRESSURIZED PIPING(Check all that apply): 10.CONTINUOUS TURBINE SUMP SENSOR WIT AUDIBLE AND VISUAL 10.CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL ALARMS AND(Chock one) ALARMS AND(Check one) ❑ 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 ❑b.AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM DISCONNECTION SYSTEM DISCONNECTION ❑ c. NO AUTO PUMP SHUT OFF ❑ C. NO AUTO PUMP SENT OFF ❑ 11.AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)WITH ❑ 11.AUTOMATIC LEAK DETECTOR FLOW SHUT OFF OR RESTRICTION ❑ 12.ANNUAL INTEGRITY TEST(0.1 GPM ❑ 12.ANNUAL INTEGRITY TEST(0.1 GPH) 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(Check all thatapply) EMERGENCY GENERATORS ONLY(Check all that apply) ❑ 14.CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF• ❑ 14.CONTINUOUS SUMP SENSOR WITHOITf AUTO PUMP SHUT OFF AUDIBLE AND VISUAL ALARMS AUDIBLE AND VISUAL ALARMS ❑ 15.AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)WITHOUT FLOW ❑ 15.AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)WITHOUT FLOW SHUT OFF OR RESTRICTION SHUT OFF OR RESTRICTION ❑ 16.ANNUAL INTEGRITY TEST(0.1 GPIH ❑ 16.ANNUAL INTEGRITY TEST(0.1 GPH) ❑ 17.DAILY VISUAL CHECK ❑ 17.DAILY VISUAL CHECK VIII.DISPENSER CONTAINMENT DISPENSER CONTAINMENT ❑ 1.FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE ❑4.DAILY VISUAL CHECK DATE INSTALLED 46a ❑ 2.CONTINUOUS DISPENSER PAN SENSOR+AUDIBLE AND VISUAL ALARMS ❑ 5.TRENCH LINER/MONITORING ❑ 3.CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR ❑ 6.NONE DISPENSER+AUDIBLE AND VISUAL ALARMS 469 IX.OWNER/OPERATOR SIGNATURE loertify that the information cyided herein u true and accurate to the ben of knowledge. SIGNATURE OF OWNER/OPERATOR DATE 470 NAME OF OWNER/OPERATOR(pnnl) TITLE OF OWNER/OPERATOR 4n an Pmmt NumM(Fm local use only) 473 Permit Approved(Fm local use oNy) 474 Permit Expration Date(For kcal use only) 475 EE0000646 12/31/199 UPCF(12/99 revised)