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FIED PROGRAM CONSOLIDATED FOR. TANK UNDERGROUND STORAGE TANKS - TANK PAGE 2 VI.PIPING CONSTRUCTION(Check an that apply) Page_of UNDERGROUND PIPING ABOVEGROUND PIPING SYSTEM TYPE 0 1.PRESSURE 0 2.SUCTION ❑3.GRAVITY 458 ❑1.PRESSURE ❑2. SUCTION ❑3.GRAVITY 459 CONSTRUCTION/ ❑1.SINGLE WALL ❑3.LINED TRENCH 0 99.OTHER 460 [11.SINGLE WALL ❑95.UNKNOWN 462 MANUFACTURER 192.DOUBLE WALL [195.UNKNOWN ❑2.DOUBLE WALL ❑99,OTHER MANUFACTURER Environ 461 MANUFACTURER_ 463 ❑1.BARE STEEL 0 6.FRP COMPATIBLE w/11XMA METHANOL ❑1.BARE STEEL ❑&FRP COMPATIBLE W11W%METHANOL ❑2.STAINLESS STEEL ❑7.GALVANIZED STEEL ❑UKNOWN ❑2. STAINLESS STEEL ❑7.GALVANIZED STEEL [13.PLASTIC COMPATIBLE W/CONTENTS ❑99. OTHER ❑3. PLASTIC COMPATIBLE W/CONTENTS ❑8.FLEXIBLE(HDPE) ❑99. OTHER ®4.FIBERGLASS ®8.FLEXIBLE(HDPE) ❑4. FIBERGLASS ❑9.CATHODIC PROTECTION ❑5.STEEL W/COATING ❑9.CATHODIC PROTECTION 464 1 ❑5. STEEL W/COATING ❑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 466 SINGLE WALL PIPING 467 PRESSURIZED PIPING(Chxkall Matappyg PRESSURIZED PIPING(Check an that apply): 01. ELECTRONIC UNE 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. [12. MONTHLY 0.2 GPH TEST ❑2. MONTHLY 0.2 GPH TEST 03. ANNUAL INTEGRITY TEST(O.IGPH) ❑3. ANNUAL INTEGRITY TEST(0.1GPH) El 4. DAILY VISUAL CHECK CONVENTIONAL SUCTION SYSTEMS CONVENTIONAL SUCTION SYSTEMS(Check all that apply) 05. DAILY VISUAL MONITORING OF PUMPING SYSTEM-TRIENNIAL PIPING INTEGRITY [15. 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(0A GPH) GRAVITY FLOW(Check all that api ❑8. DAILY VISUAL MONITORING [19. 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 Oc. NO AUTO PUMP SHUT OFF Oc NO AUTO PUMP SHUT OFF ®11. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)WITH FLOW SHUTOFF OR ❑11 AUTOMATIC LEAK DETECTOR RESTRICTION ®12. ANNUAL INTEGRITY TEST(0.1 GPH) [112, ANNUAL INTEGRITY TEST(0.1 GPH) SUCTION/GRAVITY SYSTEM SUCTION/GRAVITY SYSTEM 013. CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS 013. CONTINUOUS SUMP SENSOR+AUDIBLE ANDVISUALALARMS EMERGENCY GENERATORS ONLY(Check all that apply) EMERGENCY GENERATORS ONLY(Check all that apply) ❑14. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF+AUDIBLE AND ❑14. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF+AUDIBLE AND VISUALALARMS VISUALALARMS ❑15.AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)WITHOUT FLOW SHUT OFF OR ❑15. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST) RESTRICTION ❑16. ANNUAL INTEGRITY TEST(0.1 GPH) [116. ANNUAL INTEGRITY TEST(0.1 GPH) ❑17. DAILY VISUAL CHECK [117. DAILY VISUAL CHECK VIII.DISPENSER CONTAINMENT DISPENSER [31. FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE ❑4.DAILY VISUAL CHECK CONTAINMENT DATEINSTALLED 468 ❑2. NUOUS DISPENSER PAN SENSOR-AUDIBLE AND VISUAL ALARMS ❑5.TRENCH LINER I MONITORING 1998 I&3. CO INUOU&DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR DISPENSER+ 0 6.NONE 469 ' AUDIBL DVISUAL ALARMS IX.OWNERIOPERATOR SIGNATURE 1 carat'that the information pro d herein is true nd accupdeo the best of my knowledge. SIGNATURE OF OWN O DATE 479 O� NAME OF OWNER/OP TOR(Pont) TITLE OF CRIVINERIOPERATOR 472 Randy Martin Gasoline & Environmental Compliance Manager Permit Numear(For)oral use oNy) 473 Permit Approved(For local use only) Permit Expiration Date(For local use only) 475 UPCF (1/99 revised) Formerly SWRCB Form B