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IED PROGRAM CONSOLIDATED FO TANKS -rh 0 Jq Iag31 UNDERGROUND STORAGE TANKS - TANK PAGE 2 Pae of VI.PIPING CONSTRUCTION(check all that apply) UNDERGROUND PWG ABOVEGROUND PIPING SYSTEM TYPE ❑1.PRESSURE .SUCTION ❑3.GRAVITY 458. ❑1.PRESSURE ❑2.SUCTION ❑3.GRAVITY 459, CONSTRUCTION/ 1.SINGLE WALL ❑3.LINED TRENCH ❑99.OTHER 460. [11.SINGLE WALL [195.UNKNOWN 462, MANUFACTURER Cle-DOUBLE WALL ❑95.UNKNOWN ❑2.DOUBLE WALL ❑99.OTHER MANUFACTURER 461. MANUFACTURER 463. ❑1.BARE STEEL ❑6.FRP COMPATIBLE W/100%METHANOL ❑ 1.BARE STEEL [16.FRP COMPATIBLE W/100%METHANOL ❑2.STAINLESS STEEL ❑7.GALVANIZED STEEL ❑2.STAINLESS STEEL ❑7.GALVANIZED STEEL ❑3.PLASTIC COMPATIBLE WITH CONTENTS ❑95.UNKNOWN ❑3.PLASTIC COMPATIBLE W/CONTENTS 111.FLEXIBLE(HDPE) [119.OTHER .FT ERGLASS ❑S.FLEXIBLE(HDPE) [199.OTHER ❑4.FIBERGLASS [19.CATHODIC PROTECTION [:15.STEEL W/COATING [19.CATHODIC PROTECTION 464. [15.STEEL W/COATING ❑95.UNKNOWN 465, VII.PIPING LEAK DETECTION(Check all that I) A deacd lion ofthe monitcuing pmgrm shall be aubmined to the local agency,) UNDERGROUND PIPING ABOVEGROUND PIPING SINGLE WALL PIPING 466. SINGLE WALL PIPING 467. PRESSURIZED PIPING(Check all that apply): PRESSURIZED PIPING(Check all that apply): ❑1. ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP [11. 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 [12. MONTHLY 0.2 GPH TEST [13. ANNUAL INTEGRITY TEST(0.1 GPH) El 3. ANNUAL INTEGRITY TEST(0.1 GPH) ❑4. DAILY VISUAL CHECK CONVENTIONAL SUCTION SYSTEMS CONVENTIONAL SUCTION SYSTEMS(Check all that apply) [15. DAILY VISUAL MONITORING OF PUMPING SYSTEM+TRIENNIAL PIPING ❑5. DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM INTEGRITY TEST(0.1 GPH) SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): [16. TRIENNIAL INTEGRITY TEST(0.1 GPH) [17. SELF MONITORING SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): GRAVITY FLOW ❑7. SELF MONITORING [19. BIENNIAL INTEGRITY TEST(0.1 GPH) GRAVITY FLOW(Check all that apply): [18. DAILY VISUAL MONITORING [19. .BIENNIAL INTEGRITY TEST(0.1 GPH) SECONDARILY CONTAINED PIPING SECONDARILY CONTAINED PIPING PRESSURIZED PIPING(Check all that apply): PRESSURIZED PIPING(Check all that apply): 10. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL 10. CONTINUOUS TURBINE SUMP SENSOR WITS AUDIBLE AND VISUAL aALARMS AND(Check one) ALARMS AND(Check one) psa. AUTO PUMP SHUT OFF WHEN A LEAK OCCURS ❑a. AUTO PUMP SHUT OFF WHEN A LEAK OCCURS GI" AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM ❑b. AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM VV DISCONNECTION DISCONNECTION []c. NO AUTO PUMP SHUT OFF [3c. NO AUTO PUMP SHUT OFF ❑11. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)WI FLOW SHUT 11 AUTOMATIC LEAK DETECTOR OFF OR RESTRICTION ❑12. ANNUAL INTEGRITY TEST(0.1 GPH) ❑12. ANNUAL INTEGRITY TEST(0.1 GPH) SUCTION/GRAVITY SYSTEM SUCTION/GRAVITY SYSTEM Q 13. CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS ❑13. CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS EMERGENCY GENERATORS ONLY(Check all that apply) EMERGENCY GENERATORS ONLY(Check all that apply) [114. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF [114.CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF AUDIBLE AND VISUAL ALARMS AUDIBLE AND VISUAL ALARMS [115. AUTOMATIC LINE LEAK DETECTOR (3.0 GPH TEST) WITHOUT FLOW 15. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST) SHUT OFF OR RESTRICTION ❑16. ANNUAL INTEGRITY TEST(0.1 GPH) ❑16. ANNUAL INTEGRITY TEST(0.1 GPH) [117. DAILY VISUAL CHECK ❑17. DAILY VISUAL CHECK VIII.DISPENSER CONTAINMENT DISPENSER CONTAINMENT 4681. FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE [14. DAILY VISUAL CHECK 469. DATE INSTALLED [12. CONTINUOUS DISPENSER PAN SENSOR+AUDIBLE AND VISUAL ALARMS [IS. TRENCIFLINER MONITORING ❑3. CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR El 6. NONE DISPENSER+AUDIBLE AND VISUAL ALARMS IX.OWNEWOPERATOR SIGNATURE I certify at the ir4mltiong4vided herein is true and accurate to the hest of my knowledge. SIGN O R/OP TOR DATE: 470. //�D NAr OF OWNER/OPE T i t)' TITLE OF R/O RATOR• 472. G i Permit Numbs Agency we only) 473 1 Permit Approved By(Agency use only) 474. Permit Expiration Data(Agency use only) 475. UPCF hwfwrc-b(1/99)-3/4 www.unidocs.org Rev.02/16/00