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JIFIED PROGRAM CONSOLIDATED FOI; TANKS UNDERGROUND STORAGE TANKS - TANK PAGE 2 VI.PIPING CONSTRUCTION(Checkaumat I Page_of_ UNDERGROUND PIPING ABOVEGROUND PIPING SYSTEM TYPE ❑1.PRESSURE 2.SUCTION ❑3.GRAVITY 458 ❑1.PRESSURE 5F.-SUCTION ❑3.GRAVITY 459 CONSTRUCTION JZL SINGLE WALL ❑3.LINED TRENCH ❑99.OTHER 460 (!J�1.SINGLE WALL ❑95.UNKNOWN 462 MANUFACTURER ❑2.DOUBLE WALL ❑95.UNKNOWN ❑2.DOUBLE WALL ❑99.OTHER MANUFACTURER 461 MANUFACTURER 463 Q�1.BARE STEEL ❑6.FRP COMPATIBLE w/100% METHANOL [:11.BARE STEEL ❑6.FRP COMPATIBLE W/100%METHANOL /❑2.STAINLESS STEEL ❑7.GALVANIZED STEEL ❑Unknown ❑2. STAINLESS STEEL ❑7.GALVANIZED STEEL ❑3.PLASTIC COMPATIBLE W/CONTENTS ❑99. Other C13. 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 ❑5. STEEL W/COATING ❑95.UNKNOWN 465 VII.PIPING LEAK DETECTION Check all that I A descn non of the monitonng prolpsurnshall be subtnitmd to the local a UNDERGROUND PIPING ABOVEGROUND PIPING SINGLE WALL PIPING 466 SINGLE WALL PIPING 467 PRESSURIZED PIPING(Check all tut apply): PRESSURIZED PIPING(Check all that apply): Cl 1.ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP SHUT ❑I. ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WM AUTO PUMP OFF FOR LEAK,SYSTEM FAILURE,AND SYSTEM DISCONNECTION+ SHUT OFF FOR LEAK,SYSTEM FAILURE,AND SYSTEM ASCONNP.CTION AUDIBLE AND VISI IAl ALAE,-S. i JDIBLE AND VISUAL ALARMS. ❑2.MONTHLY 0.2 GPH 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(Cheek ail that apply) ❑5.DAILY VISUAL MONITORING OF PUMPING SYSTEM+TRIENNIAL PIPING INTEGRITYTESTTEST(0.1 GPH) S. DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM 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. SELF MONITORING ❑9.BIENNIAL INTEGRITY TEST(0.I GPH) GRAVITY FLOW(Check all that apply): ❑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 10. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL ALARMS AND(Check one) ALARMS AND(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 ❑11 AUTOMATIC LEAK DETECTOR OFF OR RESTRICTION ❑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(Chak au thatapply) EMERGENCY GENERATORS ONLY(Check ail that apply) ❑14. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF• ❑14. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF AUDIBLE AND VISUAL ALARMS AUDIBLE AND VISUAL ALARMS ❑ 15. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)WITHOUT FLOW ❑15. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST) 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 ❑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.CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR 4!�6.NONE 469 �.'U(; DISPENSER+AUDIBLE AND VISUAL ALARMS IX.OWNER/OPERATOR SIGNATURE I ccm fY that the information provided heroin is Inc and,arun to the best of my knowledge. SIGNATURE OF OWNER/OPERATOR DATE 470 NAME OF 0 ER/OPRATORce�mQ �' 471 TITLE OF 0 R/OPERATOK 472 r//," 1) .9 /£ D�✓,�� ,2 roma Numbcr(For local use only) 473 Permit App-d(FWlocal use only) 474 Permit Expiranon Date(For local use only) 475 UPCF(12/99 revised) 12 Formerly SWRCB Form B