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UNERGROUND STORAGE TA TANK PAGE 2 UNIFIED PROGRAM CONSOLIDATED FGRM FRESNO COUNTY HUMAN SERVICES SYSTEM-DEPARTMENT OF COMMUNITY HEALTH-ENVIRONMENTAL HEALTH SYSTEM Page of VI.PIPING CONSTRUCTION(Check all that apply) UNDERGROUND PIPING ABOVEGROUND PIPING SYSTEM TYPE 1:11 PRESSURE 2. SUCTION El 3. GRAVITY 458 ❑ 1. PRESSURE 1:12. SUCTION El 3. GRAVITY 459 CONSTRUCTIONI 1. SINGLE WALL ❑ 3. LINED TRENCH 1-199. OTHER 460 ❑ 1. SINGLE WALL ❑95. UNKNOWN 462 MANUFACTURER❑ 2. DOUBLE WALL ❑95. UNKNOWN ❑ 2. DOUBLE WALL ❑99. OTHER MANUFACTURER 461 MANUFACTURER 463 91 1.BARE STEEL ❑ 6. FRP COMPATIBLE Wl 100%METHANOL El 1.. BARE STEEL EJ6. FRP COMPATIBLE Wt 100%METHANOL MATERIALS AND ❑ 2. STAINLESS STEEL ❑ 7. GALVANIZED STEEL ❑ 2. STAINLESS STEEL ❑ 7. GALVANIZED STEEL CORROSION ❑ PROTECTION 3. PLASTIC COMPATIBLE WITH CONTENTS ❑95. UNKNOWN ❑ 3. PLASTIC COMPATIBLE WITH CONTENTS El8. FLEXIBLE(HDPE) ❑99. OTHER ❑ 4. FIBERGLASS ❑ S. FLEXIBLE(HDPE) E199 OTHER ❑ 4. FIBERGLASS ❑ 9. CATHODIC PROTECTION ❑ 5- STEEL WI COATING ❑ 9. CATHODIC PROTECTION 464 ❑ 5. STEEL Wl COATING ❑95. UNKNOWN 465 VIL PIPING LEAK DETECTION(Check aff that apply) 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 SHUT OFF FOR ❑ 1. ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP SHUT OFF FOR LEAK. LEAK,SYSTEM FAILURE,AND SYSTEM DISCONNECTION+AUDIBLE AND VISUAL SYSTEM FAILURE,AND SYSTEM DISCONNECTION+AUDIBLE AND VISUAL ALARMS ALARMS ❑ 2. MONTHLY 0,2 GRH 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: CONVENTIONAL SUCTION SYSTEMS(Check all that apply): ❑ 5. DAILY VISUAL MONITORING OF PUMPING SYSTEM*TRIENNIAL PIPING INTEGRITY ❑ 5. DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM ry TEST(0.1 GPH) ❑ 6. TRIENNIAL INTEGRITY TEST(0.1 GPH) SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING)_ ❑ 7. SELF MONITORING ❑ 7. SELF MONITORING GRAVITY FLOW: GRAVITY FLOW(Check all that apply): ❑ 9. BIENNIAL INTEGRITY TEST(0.1 GPH) ❑ 8. DAILY VISUAL MONITORING ❑ 9. 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 ALARMS AND 10.CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL ALARMS AND(check one) (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 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)WITH FLOW SHUT OFF OR ❑ 11. AUTOMATIC LEAK DETECTOR RESTRICTION ❑ 12. ANNUAL INTEGRITY TEST(0.t GPH) © 12. ANNUAL INTEGRITY TEST(0.1 GPH) SUCTION/GRAVITY SYSTEM: SUCTIONIGRAVITY SYSTEM: ❑ 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 af)that apply) ❑ 14. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF+AUDIBLE AND ❑ 14. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF+AUDIBLE AND VISUAL VISUAL ALARMS ALARMS ❑ 15. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)WITHOUT FLOW SHUT OFF OR ❑ 15. AUTOMATIC LINE LEAK DETECTOR(3.0 GRH TEST) RESTRICTION ❑ 16. ANNUAL INTEGRITY TEST(0.1 GPH) ❑ 16. ANNUAL INTEGRITY TEST(0.1 GPH) - ❑ 17. DAILY VISUAL CHECK ❑ 17. DAILY VISUAL CHECK Vlil.DISPENSER CONTAINMENT DISPENSER CONTAINMENT ❑ 1. FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE ❑ 4. DAILY VISUAL CHECK DATE INSTALLED 468 ❑ 2. CONTINUOUS DISPENSER PAN SENSOR+AUDIBLE AND VISUAL ALARMS ❑ 5. TRENCH LINER/MONITORING ❑ 3. CONT3NUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR DISPENSER+AUDIBLE AND VISUAL ALARMS ❑ 6_ NONE 469 IX.OWNER/OPERATOR SIGNATURE I certtfy that the information provided herein is true and accurate to the best of my knowledge. SIGNATUREOF OWNER/OPERATOR DATE 470 I NAME OF OWNERlOPERATOR(print) 1 471 TITLE OF OWNERlOPERATOR 1 472 W ! ' '00Z/L `,�. i ZIP C' }Z- 46�.�'r' Permit Number(Forlocal use only) 473 Permit Approved(For local use only) - 474 Permit Expiration Data(Forlocal use only) 475 HSS-1018 UPCF(4199) F:ICUPAIFORMSIUSTFRM03.WPT Formerly SWRCB Form B