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IFIED PROGRAM CONSOLIDATED F <br /> TANK <br /> UNDERGROUND STORAGE TANKS TANK PAGE 2 <br /> VI.PIPING CONSTRUCTION(Check all that apply) Pagc 2 of 6 <br /> UNDERGROUND PIPING ABOVEGROUND PIPING <br /> SYSTEM TYPE ®1.PRESSURE 0 2.SUCTION 0 3.GRAVITY 458 0 1.PRESSURE 0 2. SUCTION 0 3.GRAVITY 459 <br /> CONSTRUCTION 0 1.SINGLE WALL [13.LINED TRENCH 0 99.OTHER 460 0 L SINGLE WALL 0 95.UNKNOWN 462 <br /> MANUFACTURER ®2.DOUBLE WALL [195.UNKNOWN 0 2.DOUBLE WALL 0 99.OTHER <br /> MANUFACTURER AO Smith 461 MANUFACTURER_ 463 <br /> 0 1.BARE STEEL ❑6.FRP COMPATIBLE w/l00% METHANOL 0 1.BARE STEEL 0 6.FRP COMPATIBLE W/196%METHANOL <br /> 0 2.STAINLESS STEEL [17.GALVANIZED STEEL 0 Unknown 0 2. STAINLESS STEEL 0 7.GALVANIZED STEEL <br /> 0 3.PLASTIC COMPATIBLE W/CONTENTS [199. Other 0 3. PLASTIC COMPATIBLE W/CONTENTS 0 8.FLEXIBLE(HDPE) 0 99. OTHER <br /> ®4.FIBERGLASS 0 8.FLEXIBLE(HDPE) 0 4. FIBERGLASS 0 9.CATHODIC PROTECTION <br /> 0 5.STEEL W/COATING 0 9.CATHODIC PROTECTION 464 0 5. STEEL W/COATING 0 95.UNKNOWN 465 <br /> VII.PIPING LEAK DETECTION(Check all thatapply)(A description ofthe monitoring praginart shall M submitted to the local agency) <br /> UNDERGROUND PIPING ABOVEGROUND PIPING <br /> SINGLE WALL PIPING 466 SINGLE WALL PIPING 467 <br /> PRESSURIZED PIPING(Check all then apply): PRESSURIZED PIPING(Check all that apply): <br /> 0 1.ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP SHUT 0 1. ELECTRONIC LANE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP <br /> OFF FOR LEAK,SYSTEM FAILURE,AND SYSTEM DISCONNECTION+ SHUT OFF FOR LEAK,SYSTEM FAILURE,AND SYSTEM DISCONNECTION+ <br /> AUDIBLE AND VISUAL ALARMS. AUDIBLE AND VISUAL ALARMS. <br /> [12.MONTHLY 0.2 GPH TEST [12. MONTHLY 0.2 GPH TEST <br /> 0 3.ANNUAL INTEGRITY TEST(0.1GPH) 0 3.ANNUAL INTEGRITY TEST(0.1GPH) <br /> [14. DAILY VISUAL CHECK <br /> CONVENTIONAL SUCTION SYSTEMS CONVENTIONAL SUCTION SYSTEMS(Check all that apply) <br /> ❑5.DAILY VISUAL MONITORING OF PUMPING SYSTEM+TRIENNIAL PIPING 0 S. DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM <br /> INTEGRITY TEST(0.1 GPH) <br /> SAFE SUCTION SYSTEMS(NO VALUES IN BELOW GROUND PIPING): [16. TRIENNIAL INTEGRITY TEST(0.1 GPH) <br /> [17.SELF MONITORING SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): <br /> GRAVITY FLOW 07. SELF MONITORING <br /> 0 9.BIENNIAL INTEGRITY TEST(0.1 GPH) GRAVITY FLOW(Check all thin apply): <br /> 0 8. DAILY VISUAL MONITORING <br /> 0 9. BIENNIAL INTEGRITY TEST ILL GPH) <br /> SECONDARILY CONTAINED PIPING SECONDARILY CONTAINED PIPING <br /> PRESSURIZED PIPING(Check all that apply): PRESSURIZED PIPING(Check all that apply): <br /> 10. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL 10. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL <br /> ALARMS AND(Check ane) ALARMS AND(Chock one) <br /> 0 a. AUTO PUMP SHUT OFF WHEN A LEAK OCCURS 0 a AUTO PUMP SHUT OFF WHEN A LEAK OCCURS <br /> 0 b. AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM 0 b AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM <br /> DISCONNECTION DISCONNECTION <br /> 0c. NO AUTO PUMP SHUT OFF 0c NO AUTO PUMP SHUT OFF <br /> ® <br /> 11. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)WITH FLOW SHUT <br /> OFF OR RESTRICTION ❑11. AUTOMATIC LEAK DETECTOR <br /> ®12. ANNUAL INTEGRITY TEST(0.1 GPH) [112. ANNUAL INTEGRITY TEST(0.1 GPH) <br /> SUCTION/GRAVITY SYSTEM SUCTION/GRAVITY SYSTEM <br /> 0 13. CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS 0 13. CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS <br /> EMERGENCY GENERATORS ONLY(Check all that apply) EMERGENCY GENERATORS ONLY(Chock Al that apply) <br /> 0 14. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF• 0 14. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF' <br /> AUDIBLE AND VISUAL ALARMS AUDIBLE AND VISUAL ALARMS <br /> [115. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)WITHOUT FLOW 0 15. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TES <br /> SHUT OFF OR RESTRICTION T) <br /> [116.ANNUAL INTEGRITY TEST(0.1 GPH) 0 16.ANNUAL INTEGRITY TEST(0.1 GPH) <br /> 017. DAILY VISUAL CHECK 017. DAILY VISUAL CHECK <br /> VIII.DISPENSER CONTAINMENT <br /> DISPENSER CONTAINMENT 0 I.FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE 0 4.DAILY VISUAL CHECK <br /> DATE INSTALLED 468 ®2.CONTINUOUS DISPENSER PAN SENSOR+AUDIBLE AND VISUAL ALARMS 0 5.TRENCH LINER/MONITORING <br /> 9/28/90 0 3.CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR 0 6.NONE 469 <br /> DISPENSER+AUDIBLE AND VISUAL ALARMS <br /> IX.OWNER/OPERATOR SIGNATURE <br /> I cenify that the informatlo 'd er ist end to to thebest of my knowledge. <br /> SIGNATURE OF A DATE 470 <br /> QW,LE9U 5/30/02 <br /> NAME OF OWNER/O TOR Trint) TITLE OF OWNER/OPERATOR 472 <br /> Chevron Products Co /D.R. LERI Retail ESH Specialist <br /> Pernik Number(For local use only) 473 Penin Appoi c (For local me only) Permit Expiration Date(For local use only) 4]5 <br /> UPCF(1/99 revised) 174 Formerly SWRCB Form B <br />