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WIFIED PROGRAM CONSOLIDATED FOR* TANK: TA0515724 PR#: PRO522519 UNDERGROUND STORAGE TANKS - TANK PAGE 2 FAC#: FA0015337 VL PIPING CONSTRUCTION(Ckck aE mol apply) UNDERGROUND PIPING I.PRESSURE N,3.0 SYSTEM I'YPE ❑ ABOVEGROUND PIPING ® 2.SUCTION ❑ 3.GRAVITY 45e ❑ I.PRESSURE ❑2.SUCTION ❑ 3.GRAVITY 459 CONSTRUCTION ❑1.SINGLE WALL ❑3,LINED TRENCH ❑ 99.OTHER 460 ❑ I.SINGLE WALL ❑ 95.UNKNOWN 463 ❑2.DOUBLE WALL 095.UNKNOWN ❑ 2.DOUBLE WALL MANUFACTURER 061 EI 99.OTHER MANUFACTURER 463 ® 1.BARE STEEL ❑ 6.FRP COMPATIBLE W IN:METHANOL ❑ 1.BARE STEEL ❑ 6.FRP COMPATIBLE x/IOM..METHANOL ❑ 2.STAINLESS STEEL ❑ 7.GALVANIZED STEEL ❑ 2.STAINLESS STEEL ❑ 7.GALVANIZED STEEL ❑ PLASTIC COMPATIBLE W/CONTENTS ❑ 95.UNKNOWN ❑ PLASTIC COMPATIBLE W/CONTENTS ❑ 95.UNKNOWN ❑4.FIBERGLASS ❑ 8.FLEXIBLE(HDPE) ❑ 99.OTHER [14.FIBERGLASS ❑ 8.FLEXIBLE(HDPE) ❑ 99.OTHER ❑5.STEEL W/COATING ❑ 9.CATHODIC PROTECTION 46J ❑5.STEEL W/COATING 1:19 CATHODIC PROTECTION 965 V0.PIPING LEAK DETECTION(Ckok all mat apply)(A bamlplim afum moalmrmpmlp e am Oat k sunmmm w the keel Vett,) UNDERGROUND PIPMr. ABOVEGROUND PIPING SINGLE WALL PIPING SINGLE WALL PIPING PRESSURIZED PIPING(Check all that apply): ED PIPING(Check ell that apply): 467 ❑ 1.ELECTRONIC LME LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP SHUT CTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP SHUT OFF FOR LEAK,SYSTEM FAILURE,AND SYSTEM DISCONNECTION+pUDD3LE ANEAK,SYSTEM FAILURE,AND SYSTEM DISCONNECTION+AUDIBLE AND VISUAL ALARMS. L ALARMS, ❑2.MONTHLY 0.2 GPH TEST ❑3.ANNUAL INTEGRITY TEST(0.1 GPH) THLY 0.2 GPH TEST ❑ 3.ANNUAL INTEGRITY TEST(0.1 GPH) Y VISUAL CHECK CONVENTIONAL SUCTION SYSTEMS ONAL SUCTION SYSTEMS(Check all that apply) ❑ 5.DAILY VISUAL MONITORING OF PUMPING SYSTEM+TRIENNIEAL PIPING ❑ 5.DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM INTEGRITY TEST(0.1 GPH) ❑b.TRIENNIAL INTEGRITY TEST(0.1 GPH) SAFE SUCTION SYSTEMS(NO VALUES IN BELOW GROUNDPIPING): ❑ 7SELF MONITORING SAFE SUCTION SYSTEMS(NO VALUES IN BELOW GROUNDPIPING): . GRAVITY FLOW ❑ 7.SELF MONITORING ❑9.13MMI L INTEGRITY TEST(0.1)GPH GRAVITY FLOW(Check all that apply): ❑ &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 10.CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL ALARMS AND(Check me) ALARMS AND(Ckek me) El..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 SHIT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM DISCONNECTION DISCONNECTION ❑c. NO AUTO PUMP SHUT OFF ❑ e NO AUTO PUMP SHUT OFF ❑ IL AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)WITH FLOW SHUT OFF OR RESTRICTION ❑ 11.AUTOMATIC LEAK DETECTOR ❑ 12.ANNUAL INTEGRITY TEST(0.1 GPH) ❑ 12.ANNUAL INTEGRITY TEST(0.1 GPH) SUCTION/GRAVITY SYSTEM SUCTION/GRAVITY SYSTEM ❑ 13.CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS ❑ 13.CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS EMERGENCY GENERATORS ONLY(Check au met apply) EMERGENCY GENERATORS ONLY(Cheek all Ota apply) ❑ 14.CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF a ❑ 14.CONTINUOUS SUMP SENSOR WITH UT AUDIBLE AND VISUAL ALARMS AUDIBLE AND VISUAL ALARMS AUTO PUMP SHUT OFF 15.AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)WITHOUT FLOW ❑ SHUT OFF OR RESTRICTION ❑ SH AUTOMATIC LOPE LEAK DETECTOR(3.0 GPH TEST)WITHOUT FLOW SHUT OFF OR RESTRICTION ❑ 16.ANNUAL INTEGRITY TEST(0.1 GPH) ❑ 16.ANNUAL INTEGRITY TEST(0.1 GPH) ❑ 17.DAILY VISUAL CHECK ❑ 17.DAILY VISUAL CHECK VIII.DISPENSER CONTAINMENT DISPENSER CONTAINMENT 459 El FLOAT MECHANISM DATE INSTALLED THAT SHUTS OFF SHEAR VALVE E] 4.DAILY VISUAL CHECK El 2.CONTINUOUS DISPENSER PAN SENSOR+AUDIBLE AND VISUAL ALARMS El 5.TRENCH LINER/MONITORING ❑3.CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR ® 6.NONE DISPENSER+AUDIBLE AND VISUAL ALARMS d470 IX OWNEWUPERATOR SIGNATURE I calify mat lk inf Tim proidW klcin is live and eoewateto lk kst ofmrFvwxIWee. SIGNATURE OF OWNERIOPERATOR DATE NAME OF OWNEWOPERATOR(print) TITLE OF OWNER/OPERATOR WILLIAM LITTLE 071 AGENT-GEOLOGIST 472 Pormil Numkr(Fm lural uaemlc) 473 Permit App.rW(For lural use mly) 474 Pmnit ExAim ontion Dalc(For k-I wo h) 475 UPCF(12/99 revised)