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ANIL Ask low NIFIED PROGRAM CONSOLIDATED FORM TANKS UNDERGROUND STORAGE TANKS -TANK PAGE 2 Pace of `- VI.PIPING CONSTRUCTION(Checka9 mat UNDERGROUND PIPING ABOVEGROUNDPIPING SYSTEM TYPE PRESSURE ❑ 2.SUCTION ❑ 3.GRAVITY ❑ 1. PRESSURE ❑ 2. SUCTION ❑ 3. GRAVITY CONSTRUCTION/ f❑ 1 GLE WALL ❑ 3. UNED TRENCH ❑99.OTHER ❑ 1.SINGLE WALL ❑95. UNKNOWN MANUFACTURER gyp. DOUBLE WALL //�� ❑95.UNKNqwr+ 112.DOUBLE WALL 1199. OTHER MANUFACTURER riN4I(Caz MANUFACTURER ❑ 2.1.HARE STEEL ❑ B. FRP COMPATIBLE WI 100%METHANOL 111. BARESTEEL 11111. FRPCOMPATIBLEWf IW%METHANOL MATERIALSAND ❑ STAINLESS STEEL ❑ T.GALVANMEDSTEEL ❑2. STAINLESSSTEEL ❑ T.GALVANIZEDSTEEL CORROSION PROTECTION ❑ 3.PLASTIC COMPATIBLE WITH CONTENTS ❑95.UNKNOWN ❑ 3. PLASTIC COMPATIBLE WITH CONTENTS ❑ B. FLEXIBLE(HDPE) _❑99.OTHER.' 114. FIBERGLASS ❑ 8.FLEXIBLE(HDPE) 0-f OTHER ❑ 4.FIBERGLASS - ❑ 9. CATHODICPROTECNON ID S.STEEL WI COATING ❑ 9.CATHODIC PROTECTION ❑ 5. STEEL WICOATING 1195, UNKNOWN 'Al.PIPING LEAK DETECTION(Check M that aypy)y P y-a.r .,.. m ....,. rrr Y' UNDERGROUND PIPING ABOVEGROUND PIPING SINGLE WALL PIPING SINGLEWALLPIPING PRERIZED PIPING(Checkaf/IhalepFW: PRESSURIZED PIPING(Chocka8 MlappOg - 1.ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP SHUT OFF FOR ❑ 1. ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP SHUT OFF FOR LEAK - LEAKSYSTEMFAILURE,AND SYSTEM DISCONNECTION•AUDIBLE AND VISUAL SYSTEM FAILURE.AND SYSTEM DISCONNECTION*AUDIBLE AND VISUAL ALARMS ALARMS ❑ 13 2. MONTHLY0.2 GPH 2.MONTHLY0.2GPH TEST 13 3. TES J.ANNUAL INTEGRITY TEST(0.1 GPH) . ❑ 3.ANNUAL INTEGRITY TEST(0.1 GPM) ❑ t. DAILY VISUAL CHECK . CONVENTIONAL SUCTION SYSTEMS: CONVENTIONAL SUCTION SYSTEMS(Check W that apply): ❑ S. DAILY VISUAL MONITORING OF PUMPING SYSTEM TRIENNIAL PIPING INTEGRITY ❑ 5.DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM TEST(0.1 GPH) ❑ 6.TRIENNIAL INTEGRITY TEST(0.1 GPH) SAFE SUCTION SYSTEMS MO VALVES IN BELOW GROUND PIPING): SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): ❑ T. SELFMONITORING ❑ T.SELFMONITORING GRAVITY FLOW. GRAVITY FLOW(Check aft that apply): ❑ 9. BIENNIAL INTEGRITY TEST(0.1 GPH) ❑ B. DAILY VISUAL MONITORING ❑ 9. BIENNIAL INTEGRITY TEST(Ol GPH) SECONDARILY CONTAINED PIPING SECONDARILY CONTAINED PIPING PRESSURIZED PIPING(Check 89 Mat pply): PRESSURIZED PIPING(Chock atf Mat apply): 10. CONTIJone) TURBINE SUMP SENSOR WITH AUDIBLE ANOVISUALAURMS AND 10.CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUALAURMS AND(chea ane) {Clty�e/RA�UTO PUMP SHUT OFF WHEN A LEAK OCCURS ❑ e.AUTO PUMP SHUT OFF WHEN A LEAK OCCURS 11 p.DIS O 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(3.0 GPH TEST)W9TH FLOW SHUT OFF OR ❑ 11.AUTOMATIC LEAK DETECTOR RESTRICTION ' ❑ 12.ANNUAL INTEGRITY TEST(0.1 GPH) - ❑ 12.ANNUAL INTEGRITY TEST(0.1 GPH) - SUCTION GRAVITY SYSTEM: SUCTIOWGRANWY SYSTEM: ❑ 13. CONTINUOUS SUMP SENSOR-AUDIBLE AND VISUAL ALARMS ❑ 13.CONTINUOUS SUMP SENSOR i AUDIBLE AND VISUAL ALARMS' EMERGENCY GENERATORS ONLY(Greek e90+af apply) EMERGENCY GENERATORS ONLY(Chack as met applA - ❑ 14. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF*AUDIBLE AND ❑ 14.CONTINUOUS SUMP SENSOR WATHOUT AUTO PUMP SHUT OFFS AUDIBLE AND VISUAL VISUALALARMS ALARMS ❑ 15.AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)WTHOUT FLOW SHUTOFF OR ❑ 15.AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST) - RESTRICTION - - ❑ 1e.ANNUAL INTEGRITY TEST IDA GPH) - ❑ 16.ANNUAL INTEGRITY TEST(0.1 GPH) ❑ 17. DAILY VISUAL CHECK ❑ 17. DAILY VISUAL CHECK g VXI.DISPENSER CONTAINMENT DISPENSER CONTAINMENT ❑ n +� 1.FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE ❑ d. GAILY VISUAL CHECK DATEINSTALLED 1122 TINUOUS DISPENSER PAN SENSOR•AUDIBLE AND VISUAL ALARMS - 11 5.TRENCH UNER I MONITORING CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR DISPENSER-AUDIBLEAND VISUAL ALARMS ❑ B. NONE -IX.OWNEMPERATOR SIGNATURE. I wn9>mal ma Information provided herein is true and accurate to me heal of my krm ge. SIGNATURE OF OWNERIOPERATOR PATE NAME OF OWHERIOPERATOR(prin) TITLEOFOWNERrOPERATOR Permit Number(Formcal uas ortyl Permh Appmved(porlr usnany, Pemd Ex moknDale(Forb 1...ely) CUPAFORM(4199) Folmetly SWRCB Form B