Laserfiche WebLink
MATED <br />TANK <br />UNDERGROUND STORAGE TANKS - TANK PAGE 2 <br />O 1. BARE STEEL <br />VI. PIPING CONSTRUCTION (Cheastl that apply) <br />Page _ of <br />UNDERGROUND PIPING <br />0 6. FRP COMPATIBLE W/tom METHANOL <br />0 2. STAINLESS STEEL <br />ABOVEGROUND PIPING <br />SYSTEM TYPE 0 1. PRESSURE <br />0 2. SUCTION <br />0 3. GRAVITY 456 <br />0 1. PRESSURE <br />❑ 2. SUCTION ❑ 3. GRAVITY 459 <br />CONSTRUCTION / 0 1. SINGLE WALL <br />❑ 3. LINED TRENCH <br />0 99. OTHER 460 <br />❑ 1. SINGLE WALL <br />0 95. UNKNOWN 462 <br />MANUFACTURER ® 2. DOUBLE WALL <br />0 95. UNKNOWN <br />09. CATHODIC PROTECTION <br />0 2. DOUBLE WALL <br />❑ 99. OTHER <br />MANUFACTURER Environ <br />1 0 5. STEEL W/COATING <br />461 <br />MANUFACTURER <br />463 <br />O 1. BARE STEEL <br />0 6. FRP COMPATIBLE W/100% ME 01. <br />0 1. BARE STEEL <br />0 6. FRP COMPATIBLE W/tom METHANOL <br />0 2. STAINLESS STEEL <br />0 7. GALVANIZED STEEL 0 UKNOWN <br />0 2. STAINLESS STEEL <br />0 7. GALVANIZED STEEL <br />03. PLASTIC COMPATIBLE <br />W/ CONTENTS 099. OTHER <br />03. PLASTIC COMPATIBLE W1 CONTENTS <br />08. FLEXIBLE (HDPE) 099. OTHER <br />04. FIBERGLASS <br />®8.FLEXIBLE (HDPE) <br />04. FIBERGLASS <br />09. CATHODIC PROTECTION <br />0 5. STEEL W/COATING <br />0 9. CATHODIC PROTECTION 464 <br />1 0 5. STEEL W/COATING <br />❑ 95. UNKNOWN 465 <br />VII. PIPING LEAK DETECTION (Check all that apply) (A description of the monitorinc program shall be submitted to the local agenov.I <br />SINGLE WALL PIPING 466 <br />PRESSURIZED PIPING (Check all that apply): <br />❑ 1. ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP SHUT OFF FOR <br />LEAK, SYSTEM FAILURE, AND SYSTEM DISCONNECTION -AUDIBLE ANDVISUAL <br />ALARMS. <br />[12. MONTHLY 0.2 GPH TEST <br />03. ANNUAL INTEGRITY TEST(0.1GPH) <br />CONVENTIONAL SUCTION SYSTEMS <br />❑5. DAILY VISUAL MONITORING OF PUMPING SYSTEM -TRIENNIAL PIPING INTEGRITY <br />TEST (0.1 GPH) <br />SAFE SUCTION SYSTEMS (NO VALUES IN BELOW GROUNDPIPING): <br />❑7. SELFMONITORING <br />GRAVITY FLOW <br />❑9. BIENNIAL INTEGRITY TEST (0.1 GPH) <br />SECONDARILY CONTAINED PIPING <br />PRESSURIZED PIPING (Check all that apply): <br />10. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL ALARMSAND <br />(Check one) <br />0a. AUTO PUMP SHUT OFF WHEN A LEAK OCCURS <br />[9b. AUTO PUMP SHUT OFF FOR LEAKS, SYSTEM FAILURE AND SYSTEM <br />DISCONNECTION <br />Oc. NOAUTOPUMPSHUTOFF <br />011. AUTOMATICLINE LEAK DETECTOR(3.0 GPH TEST) WITH FLOW SHUTOFF OR <br />RESTRICTION <br />012. ANNUAL INTEGRITY TEST (0.1 GPH) <br />SUCTION/GRAVITY SYSTEM <br />013. CONTINUOUS SUMP SENSOR -AUDIBLE AND VISUAL ALARMS <br />EMERGENCY GENERATORS ONLY (Chem all that apply) <br />014. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF - AUDIBLE AND <br />VISUALALARMS <br />015. AUTOMATIC LI NE LEAK DETECTOR (3.0 GPH TEST) WITHOUT FLOW SHUT OFF OR <br />RESTRICTION <br />016. ANNUAL INTEGRITY TEST (0.1 GPH) <br />017. DAILY VISUAL CHECK <br />VIII. DISPEL <br />SINGLE WALL PIPING 467 <br />PRESSURIZED PIPING( Check all that apply): <br />01. ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP SHUT OFF FOR <br />LEAK, SYSTEM FAILURE, AND SYSTEM DISCONNECTION - AUDIBLE AND VISUAL <br />ALARMS, <br />02. MONTHLY 0.2 GPH TEST <br />03. ANNUAL INTEGRITY TEST(OAGPH) <br />04. DAILY VISUAL CHECK <br />CONVENTIONAL SUCTION SYSTEMS (check all that apply) <br />05. DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM <br />❑6. TRIENNIAL INTEGRITY TEST (0.1 GPH) <br />SAFE SUCTION SYSTEMS (NO VALVES IN BELOW GROUND PIPING): <br />0 7. SELF MONITORING <br />GRAVITY FLOW (Check all that apply(: <br />08. DAILY VISUAL MONITORING <br />[19. BIENNIAL INTEGRITY TEST (0.1 GPH) <br />SECONDARILY CONTAINED PIPING <br />PRESSURIZED PIPING (Check all that apply): <br />10. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL ALARMS AND <br />(Check oro) <br />0a AUTO PUMP SHUT OFF WHEN A LEAK OCCURS <br />❑ b AUTO PUMP SHUT OFF FOR LEAKS, SYSTEM FAILURE AND SYSTEM <br />DISCONNECTION <br />Oc NO AUTO PUMP SHUT OFF <br />011. AUTOMATIC LEAK DETECTOR <br />012. ANNUAL INTEGRITY TEST (0.1 GPH) <br />SUCTION/GRAVITY SYSTEM <br />013. CONTINUOUS SUMP SENSOR. AUDIBLE AND VISUAL ALARMS <br />EMERGENCY GENERATORS ONLY (Check all that apply) <br />014. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF +AUDIBLE AND <br />VISUALALARMS <br />015. AUTOMATIC LINE LEAK DETECTOR (3.0 GPH TEST) <br />016. ANNUAL INTEGRITY TEST (0.1 GPH) <br />017. DAILY VISUAL CHECK <br />CONTAINMENT 01. FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE 04. DAILY VISUAL CHECK <br />DATEINSTALLED 468 ❑2. CONTINUOUS DISPENSER PAN SENSOR« AUDIBLE AND VISUAL ALARMS C1 5. TRENCH LINER/ MONITORING <br />2003 03. CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR DISPENSER. 0 6. NONE 469 <br />AUDIBLE AND VISUAL ALARMS <br />IX. OWNERIOPERATOR SIGNATURE <br />I certify Net the information provided herein is true and accurate to the best of my knowledge. <br />SIGNATU�NER/OP RATOR DATE470 <br />Ov�1-, oe <br />NAME OF OWNER/OPRATOR (print) TITLE OF OWNERIOPERATOR 472 <br />Ian Moorhead I Region Gasoline Environmental Compliance Manager <br />Permit Number (For local use only) 473 Permit Approved (For local use only) Permit Expiration Date (For local use only) <br />475 <br />UPCF (1/99 revised) Formerly SWRCB Form B <br />