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IFIED PROGRAM CONSOLIDATED FO T 4111111'r '11111110 I2 �/ °Z TANK UNDERGROUND STORAGE TANKS TANK PAGE 2 VI.PIPING CONSTRUCTION(Check an shat apply) Page 6 of 6 UNDERGROUND PIPING ABOVEGROUND PIPING SYSTEM TYPE ®1.PRESSURE ❑2.SUCTION [13.GRAVITY 158 ❑ 1.PRESSURE [12. SUCTION [13.GRAVITY 459 CONSTRUCTION ❑1.SINGLE WALL [13.LINED TRENCH [199.OTHER 460 [11.SINGLE WALL [195.UNKNOWN 462 MANUFACTURER ®2.DOUBLE WALL ❑95.UNKNOWN ❑2.DOUBLE WALL ❑99.OTHER MANUFACTURER AO Smith 461 MANUFACTURER_ 463 131.BARE STEEL ❑6.FRP COMPATIBLE w/10fMA METHANOL ❑1.BARE STEEL [16.FRP COMPATIBLE W/10044 METIANOL [12.STAINLESS STEEL ❑7.GALVANIZED STEEL ❑Unknown ❑2. STAINLESS STEEL 0 7.GALVANIZED STEEL [13.PLASTIC COMPATIBLE W/CONTENTS [199. Other ❑3. PLASTIC COMPATIBLE W/CONTENTS [18.FLEXIBLE(HDPE) [199. OTHER N 4.FIBERGLASS ❑S.FLEXIBLE(HDPE) [14. FIBERGLASS [19.CATHODIC PROTECTION ❑5.STEEL W/COATING ❑9.CATHODIC PROTECTION 464 [15. STEEL W/COATING [195.UNKNOWN 465 VII.PIPING LEAK DETECTION(Check all that appl)(A description ofthe monitonng pro am shall be submitted to 0rc local agency.) UNDERGROUND PIPING ABOVEGROUND PIPING SINGLE WALL PIPING 466 SINGLE WALL PIPING 467 PRESSURIZED PIPING(Check all that apply): PRESSURIZED PIPING(Check all that appy): ❑1.ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP SHUT [11. ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP OFF FOR LEAK,SYSTEM FAILURE,AND SYSTEM DISCONNECTION+ SHUT OFF FOR LEAR,SYSTEM FAILURE,AND SYSTEM DISCONNECTION+ AUDIBLE AND VISUAL ALARMS. AUDIBLE AND VISUAL ALARMS. ❑2.MONTHLY 0.2 GPH TEST ❑2. MONTHLY 0.2 GPH TEST [13.ANNUAL INTEGRITY TEST(0.IGPH) ❑3.ANNUAL INTEGRITY TEST(O.IGPH) [14. DAILY VISUAL CHECK CONVENTIONAL SUCTION SYSTEMS CONVENTIONAL SUCTION SYSTEMS(Check all that apply) [15.DAILY VISUAL MONITORING OF PUMPING SYSTEM+TRIENNIAL PIPING 5. DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM INTEGRITY TEST(0.1 GPH) SAFE SUCTION SYSTEMS(NO VALUES IN BELOW GROUND PIPING): O 6. TRIENNIAL INTEGRITY TEST(0.1 GPID [17.SELF MONITORING SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): GRAVITY FLOW 07. SELF MONITORING [19.BIENNIAL INTEGRITY TEST(0.1 GPH) GRAVITY FLOW(Check all Out 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 om) 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 I]c. NO AUTO POW SHUT OFF ❑c NO AUTO PUMP SHUT OFF 19 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 GPM) ❑12. ANNUAL INTEGRITY TEST(0.1 GPI) SUCTION/GRAVITY 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 appy) [114. 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 [115. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)WITHOUT FLOW 11 15. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST) SHUT OFF OR RESTRICTION [116.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 [14.DAILY VISUAL CHECK DATE INSTALLED 468 ®2.CONTINUOUS DISPENSER PAN SENSOR+AUDIBLE AND VISUAL ALARMS ❑5.TRENCH LINER/MONITORING 1/1/96 ®3.CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR 0 6.NONE 469 DISPENSER+AUDIBLE AND VISUAL ALARMS IX.OWNERIOPERATOR SIGNATURE I ythat Dae mf v dhwcand aecmatemthe teat of any knowlNge. SIGNATURE OF OP OR DATE 470 fD R LtE9U 6/3/02 NAME OF O ATO (print) TITLE OF OWNER/OPERATOR 473 Chevron Products Company/D.R.LERI Retail ESH S ecialist Pernit Numb (For local use only) 473 Permit Approved(For local use only) Permit Expiration Date(Far local we only) 475 UPCF(1/99 revised) 178 Formerly SWRCB Form f