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IFIED PROGRAM CONSOLIDATED FOR Z' T"': TA0438304 PR#: PR0234383 FAC#: FA0003670 UNDERGROUND STORAGE TANKS -TANK PAGE VI.PIPING CONSTRUCTION(Check all Itat apply) Page 5 of UNDERGROUND PIPING ABOVEGROUND PIPING 459 SYSTEM TYPE ❑ I.PRESSURE U2.SUCTION ❑ 3.GRAVITY 456 ❑ 1.PRESSURE E32.SUCTION C] 3.GRAVITY CONSTRUCTION ❑1.SINGLE WALL ❑3.LINED TRENCH ❑ 99.OTHER 460 ❑ 1,SINGLE WALL ❑ 95.UNKNOWN 462 112.DOUBLE WALL ❑95.UNKNOWNa6: ❑ 2.DOUBLE WALL E39. 9OTHER 463 MANUFACTURER MANUFACTURER ❑ 1.BARE STEEL ❑ 6.FRP COMPATIBLE wl IGO%METHANOL ❑ I.BARE STEEL ❑ 6.FRP COMPATIBLE*IWI.METHANOL ❑ 2 STAINLESS STEEL ❑ 7.GALVANIZED STEEL ❑ 2.STAINLESS STEEL ❑ 7.GALVANIZED STEEL ❑ ❑ 95.UNKNOWN ❑ PLASTIC COMPATIBLE WJ CONTENTS ❑ 95.UNKNOWN PLASTIC COMPATIBLE Wf CONTENTS �4.FIBERGLASS El S.FLEXIBLE(HDPE) ❑ 94.OTHER ❑ 4.FIBERGLASS [:1 S.FLEXIBLE(HDPE) ❑ 99.OTHER ❑ aha ❑ 5.STEEL WICOATING ❑ 9.CATHODICPROTECTION 46 5.STEEL WICOATING ❑ 9.CATHODIC PROTECTION VII.PIPING LEAK DETECTION(Check all that apply)(A desorption orate marthoring program shall be submiucd to the local agency.) UNDERGROUND PIPING ABOVEGROUND PIPING SINGLE WALL PIPING abs SINGLE WALL PIPING 467 PRESSURIZED PIPING(Check all that apply): PRESSURIZED PIPING(Check all that apply); ❑ I.ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP SHUT OFF ❑ 1.ELECTRONIC LME LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP SHUT OFF FOR LEAK,SYSTEM FAILURE,AND SYSTEM DISCONNECTION+AUDIBLE AND FVIOSUdFL ALARMS, SYSTEM FAILURE,AND SYSTEM DISCONNECTION+AUDIBLE 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(Check all that apply) CONVENTIONAL SUCTION SYSTEMS ❑ 5.DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM ❑5.DAILY VISUAL MONITORING OF PUMPING SYSTEM+TR)ENNIEAL PIPING INTEGRITY TEST(0.I GPH) ❑ 6.TRIENNIAL INTEGRITY TEST(0.1 GPH) SAFE SUCTION SYSTEMS(NO VALUES IN BELOW GROUNDPIPING): SAFE SUCTION SYSTEMS(NO VALUES IN BELOW GROUNDPIPING): ❑ 7.SELF MONITORING ❑ 7.SELF MONITORING GRAVITY FLOW GRAVITY FLOW(Check all[bat apply): ❑ 9.BIENNIAL INTEGRITY TEST(0.1)GPH ❑ $.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 [3 It.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 E] c. NO AUTO PUMP SHUT OFF 11.AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)WITH FLOW SI4UT OFF OR ❑ 11.AUTOMATIC LEAK DETECTOR RESTRICTION ❑ 12,ANNUAL INTEGRITY TEST(0.1 GPH) F] 12.ANNUAL INTEGRITY TEST(D.l 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 all that apply) EMERGENCY GENERATORS ONLY(Check all 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)WITHOUT FLOW ❑ SHUT OFF OR RESTRICTION 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 ❑ 6.NONE 464 DISPENSER+AUDIBLE AND VISUAL ALARMS IX.OWNER/OPERATOR SIGNATURE I cenify that the inromation provided herein is Ime and accurate to the best of my knowledge azo SIGNATU O OWN R/OPFRAT094 DATE Qt NAME OF„OWIER/OPERATO t) T[TLEOFOW ER(OP„�RATOR 472 /LHt 471 tVJ�� ✓Y 474 Permit Expiration Date(For local use only) 475 Pcrmi[Ntanber(For local use only) 473 Persnit Approved(For local me only} EE0003$04 12/31/1493 PT40a3999 UPCF(12199 revised)