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do <br /> JNIFTED PROGRAM CONSOLIDATED FOr<M <br /> UNDERGROUND STORAGE TANKS - TANK PAGE 2 <br /> .,. ;TANK <br /> age_al <br /> VI PIPITTG CONSTRUCTION(gerh all that apply)'. <br /> UNDERGROUND PIPING ABOVEGROUND PIPING <br /> SYSTEM TYPE 0 1.PRESSURE 0 2.SUCTION 0 3.GRAVITY 458 01.PRESSURE 0 2. SUCTION 0 3.GRAVITY 459 <br /> CONSTRUCTION/ 0 i.SINGLE WALL 0 3.LINED TRENCH 0 99.OTHER 460 01.SINGLE WALL 0 95.UNKNOWN 462 <br /> MANUFACTURER 0 Z DOUBLE WALL 0 95.UNKNOWN D 2.DOUBLE WALL D 99.OTHER <br /> MANUFACTURER Environ 461 MANUFACTURER_ 463 <br /> 01.BARE STEEL 0 6.FRP COMPATIBLE whom MEHIANOL 01.BARE STEEL 0 6.FRP COMPATIBLE WtIW%MEMANU <br /> 0 2.STAINLESS STEEL D 7.GALVANIZED STEEL D UKNOWN D Z STAINLESS STEEL 0 7.GALVANIZED STEEL <br /> D 3.PLASTIC COMPATIBLE W/CONTENTS 0 99. OTHER 0 3. PLASTIC COMPATIBLE W/CONTENTS 0 8.FLE)USLE(HDPE) D 99. OTHER <br /> 0 4.FIBERGLASS 0 8.FLEXIBLE(HDPE) 0 4. FIBERGLASS [19.CATHODIC PROTECTION <br /> D 5.STEEL W/COATING Cl 9.CATHODIC PROTECTION 464 [IS, STEEL WICOATING ❑95.UNKNOWN 465 <br /> P.INGLEAK-DETEC: jcht&all¶iatapply)(A&s6ijN6r,00he'(ronilo� <br /> _ ring'""pragrantsha4 be submi' l0 file local a9err_Y.)'" <br /> UNDERGROUND PIPING ABOVEGROUND PIPING <br /> SINGLE WALL PIPING 466 SINGLE WALL PIPING 467 <br /> PRESSURIZED PIPING(check a#tlw1apply): PRESSURIZED PIPING(Check all thet apply): <br /> 01. ELECTRONIC UNE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP SHUT OFF FOR 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 LEAK,SYSTEM FAILURE,AND SYSTEM DISCONNECTION+AUDIBLE AND VISUAL <br /> ALARMS. ALARMS. <br /> 02. MONTHLY 0.2 GPH TEST 0 2. MONTHLY 0.2 GPH TEST <br /> 03. ANNUAL INTEGRITY TEST(O.IGPH) 03. ANNUAL INTEGRITY TEST(gIGPH) <br /> 04. DAILYVISUALCHECK <br /> CONVENTIONAL SUCTION SYSTEMS CONVENTIONAL SUCTION SYSTEMS(Ched,all lheapply) <br /> 05. DAILY VISUAL MONITORING OF PUMPING SYSTEM-TRIENNIAL PIPING INTEGRITY D5. DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM <br /> TEST(0.1 GPH) <br /> SAFE SUCTION SYSTEMS(NO VALUES IN BELOW GROUNDPIPING): 06. TRIENNIAL INTEGRITY TEST(0.1 GPH) <br /> 07. SELFMONITORING SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): <br /> GRAVITY FLOW 07. SELF MONITORING <br /> 09. BIENNIAL INTEGRITY TEST(0.1 GPH) GRAVITY FLOW(Check all that apply): <br /> 08. DAILY VISUAL MONITORING <br /> [19. BIENNIAL INTEGRITY TEST(0.1 GPH) <br /> SECONDARILY CONTAINED PIPING SECONDARILY CONTAINED PIPING <br /> PRESSURIZED PIPING(Check a0 that apply): PRESSURIZED PIPING(Check an that apply): <br /> 10. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL ALARMS AND 10. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL ALARMS AND <br /> (Check one) (ChaIlone) <br /> Da AUTO PUMP SHUT OFF WHEN A LEAK OCCURS Oa AUTO PUMP SHUT OFF WHEN A LEAK OCCURS <br /> 131b. AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM Ob AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM <br /> DISCONNECTION DISCONNECTION <br /> 9c. NO AUTO PUMP SHUT OFF Oc NO AUTO PUMP SHUT OFF <br /> 011. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)WITH FLOW SHUTOFF OR 011 AUTOMATIC LEAK DETECTOR <br /> RESTRICTION <br /> 012. ANNUAL INTEGRITY TEST(0.1 GPH) D 1Z ANNUAL INTEGRITY TEST(0.1 GPH) <br /> SUCTION/GRAVITY SYSTEM SUCTIONIGRAVITY SYSTEM <br /> 013. CONTINUOUS SUMP SENSOR AUDIBLE AND VISUAL ALARMS [113. CONTINUOUS SUMP SENSOR«AUDIBLE AND VISUAL ALARMS <br /> EMERGENCY GENERATORS ONLY(Check all that apply) EMERGENCY GENERATORS ONLY(Check all that apply) <br /> 014. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF-AUDIBLE AND 014. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF AUDIBLE AND <br /> VISUAL ALARMS VISUALAIARMS <br /> 015, AUTOMATIC UNE LEAK DETECTOR(3.0 GPH TEST)WITHOUT FLOW SHUT OFF OR D 15. AUTOMATIC UNE LEAK DETECTOR(3.0 GPH TEST) <br /> RESTRICTION <br /> 016. ANNUAL INTEGRITY TEST(BI GPH) Dib. ANNUAL INTEGRITY TEST(0.1 GPH) <br /> 017. DAILY VISUAL CHECK 017. DAILY VISUAL CHECK <br /> DISPENSER 01. FLOAT MECHANISM THAT SHUTS OFF SHEARVALVE 0 4.DAILY VISUAL CHECK <br /> CONTAINMENT <br /> DATE INSTALLED 02 CONTINUOUS DISPENSER PAN SENSOR«AUDIBLE AND VISUAL ALARMS D 5.TRENCH LINER I MONITORING <br /> 1997 ® NTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR DISPENSER« 0 6.NONE 469 <br /> AUDIBLE AND VISUAL ALARMS <br /> 1 cadKY <br /> that IMo afion provi 4 t . s bue and accurate to the best at my knowledge. <br /> SIGNAT F TORDATE 470 <br /> 7 a <br /> NAME F OWNER/OPRATOR(print) TITLE OWN ERATOR 472 <br /> Randy Martin I Environmental Manager <br /> Permit Number(For local use only) 473 Permit Approved(For local use only) Permit Expiration Dale(For local use only) <br /> 475 <br /> UPCF(1/99 revised) Formerly SWRCB Form B <br />