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al NIFIED PROGRAM CONSOLIDATED FOR, TANK UNDERGROUND STORAGE TANKS - TANK PAGE 2 VI.PIPING CONSTRUCTION(Check all that apply) papa - of UNDERGROUND PIPING ABOVEGROUND PIPING SYSTEM TYPE ®1.PRESSURE ❑2.SUCTION ❑3.GRAVITY 458 O 1.PRESSURE ❑2. SUCTION ❑3.GRAVITY 459 CONSTRUCTION/ ❑1.SINGLE WALL 0 3.LINED TRENCH ❑99.OTHER 460 ❑1.SINGLE WALL ❑95.UNKNOWN 462 MANUFACTURER ®2.DOUBLE WALL ❑95.UNKNOWN ❑2.DOUBLE WALL ❑99.OTHER MANUFACTURER Environ 461 MANUFACTURER 463 ❑1.BARE STEEL ❑6.FRP COMPATIBLE WHOD% METHANOL ❑1.BARE STEEL ❑6.FRP COMPATIBLE Wnao%METHANOL ❑2.STAINLESS STEEL ❑7.GALVANIZED STEEL ❑UKNOWN ❑2. STAINLESS STEEL ❑7.GALVANIZED STEEL ❑3.PLASTIC COMPATIBLE W/CONTENTS ❑99. OTHER 0 3. PLASTIC COMPATIBLE Al CONTENTS ❑B.FLEXIBLE(HDPE) ❑99. OTHER ®4.FIBERGLASS ®8.FLEXIBLE(HDPE) ❑4. FIBERGLASS ❑9.CATHODIC PROTECTION ❑5.STEEL W/COATING ❑9.CATHODIC PROTECTION 464 ❑5. STEEL WICOATING ❑95.UNKNOWN 465 VII.PIPING LEAK DETECTION(Check all that apply)(A description of the monitoring program shall be submitted to the local agency.) UNDERGROUND PIPING ABOVEGROUND PIPING SINGLE WALL PIPING 4% SINGLE WALL PIPING 467 PRESSURIZED PIPING(Check all Matapply): PRESSURIZED PIPING(Check all that apply): 01. 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 SYSTEM FAILURE,AND SYSTEM DISCONNECTION.AUDIBLE AND VISUAL LEAK,SYSTEM FAILURE,AND SYSTEM DISCONNECTION-AUDIBLE AND VISUAL ALARMS. ALARMS. ❑2. MONTHLY 0.2 GPH TEST ❑2. MONTHLY 0.2 GPH TEST 03. ANNUAL INTEGRITY TEST(0.1GPH) 03. ANNUAL INTEGRITY TEST(0.1GPH) 04. DAILY VISUAL CHECK CONVENTIONAL SUCTION SYSTEMS CONVENTIONAL SUCTION SYSTEMS(cbeck a that apply) i]5. DAILY VISUAL MONITORING OF PUMPING SYSTEM.TRIENNIAL PIPING INTEGRITY 05. DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM TEST(0.1 GPH) SAFE SUCTION SYSTEMS(NO VALUES IN BELOW GROUNDPIPING): ❑6. TRIENNIAL INTEGRITY TEST(0.1 GPH) ❑7. SELF MONITORING SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): GRAVITY FLOW ❑7. SELFMONITORING ❑9. BIENNIAL INTEGRITY TEST(0.1 GPH) GRAVITY FLOW(Check Wl thatapply): ❑8. DAILY VISUAL MONITORING 09. 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 NTH AUDIBLE AND VISUAL ALARMS AND 10. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL ALARMS AND (Check pre) (Check one) ❑a. AUTO PUMP SHUT OFF WHEN A LEAK OCCURS ❑a AUTO PUMP SHUT OFF WHEN A LEAK OCCURS Ob. AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM ❑b AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM DISCONNECTION DISCONNECTION Oc. NO AUTO PUMP SHUT OFF Oc NO AUTO PUMP SHUT OFF ®11. AUTOMATIC UNE LEAK DETECTOR(3.0 GPH TEST)WITH FLOW SHUTOFF OR ❑11 AUTOMATIC LEAK DETECTOR RESTRICTION ®12. ANNUAL INTEGRITY TEST(0.1 GPH) ❑12. ANNUAL INTEGRITY TEST(0.1 GPH) SUCTIONIGRAVITY SYSTEM SUCTION/GRAVITY SYSTEM ❑13. CONTINUOUS SUMP SENSOR.AUDIBLE AND VISUAL ALARMS 013. CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS EMERGENCY GENERATORS ONLY(Check all that apply) EMERGENCY GENERATORS ONLY(Check all that apply) 014. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF+AUDIBLE AND 014. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF.AUDIBLE AND VISUAL ALARMS VISUAL ALARMS ❑15. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)WITHOUT FLOW SHUT OFF OR [115. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST) RESTRICTION [116. ANNUAL INTEGRITY TEST(0.1 GPH) ❑16. ANNUAL INTEGRITY TEST(0.1 GPH) [I 1T DAILY VISUAL CHECK 017, DAILY VISUAL CHECK VIII.DISPENSER CONTAINMENT DISPENSER Ell. FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE [14.DAILY VISUAL CHECK CONTAINMENT DATEINSTALLED 466 ❑2. CONTINUOUS DISPENSER PAN SENSOR-AUDIBLE AND VISUAL ALARMS 05.TRENCH LINER/MONITORING 1998 03. CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR DISPENSER+ 0 6.NONE 489 AUDIBLE AND VISUAL ALARMS IX.OWNERIOPERATOR SIGNATURE I certify that the intern ation provided heroin is true and accurate to the best of my knowledge. SI TORE OF OWNER/OPE TO DATE 470 NAM2 �a3o3 E OF O NER/OP TOR(print) TITLE OF OWNER/OPERATOR 472 Randy Martin Environmental Manager Permtt Number(For legal use only) 473 Permit Approved(For local use only) Permit Expidl Data(For local use only) 475 UPCF(1199 revised) Formerly SWRCB Form 8