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0D PROGRAM CONSOLIDATED F TANKS UNDERGROUND STORAGE TANKS - T ANK PAGE 2 Page 2 of 2 VL PIPING CONSTRUCTION(Check all that a apply) UNDERGROUND PIPING ABOVEGROUND PIPING SYSTEM TYPE ®1.PRESSURE D 2.SUCTION [13.GRAVITY 458. D 1.PRESSURE [12.SUCTION D 3.GRAVITY 459. CONSTRUCTION/ 1.SINGLE WALL D 3.LINED TRENCH D 99.OTHER 460. D L SINGLE WALL D 95.UNKNOWN 46x. MANUFACTURER ®2 DOUBLE WALL D 95.UNKNOWN D 2.DOUBLE WALL [199.OTHER MANUFACTURER Unkown 461. MANUFACTURER 463. ❑1.BARE STEEL [16.FRP COMPATIBLE W/100%METHANOL D 1.BARE STEEL [16.FRP COMPATIBLE W/100%METHANOL ❑2.STAINLESS STEEL [17.GALVANIZED STEEL [12.STAINLESS STEEL D 7.GALVANIZED STEEL ❑3.PLASTIC COMPATIBLE WITH CONTENTS [195.UNKNOWN [13.PLASTIC COMPATIBLE W/CONTENTS [18.FLEXIBLE(HDPE) D 99.OTHER ®4.FIBERGLASS ❑8.FLEXIBLE(HDPE) [199.OTHER D 4.FIBERGLASS D 9.CATHODIC PROTECTION ❑5.STEEL W/COATING ❑9.CATHODIC PROTECTION 464. D 5.STEEL W/COATING D 95.UNKNOWN 465, VII;PIPING LEAK DETECTION(Check all that apply)(A dacriyd9n ofthe man owing proam shall be submitted to the 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 apply): ❑1. ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO POMP [11. ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP SHUT-OFF FOR LEAK,SYSTEM FAILURE,AND SYSTEM DISCONNECTION SHUT OFF FOR LEAK,SYSTEM FAILURE,AND SYSTEM DISCONNECTION +AUDIBLE AND VISUAL ALARMS. +AUDIBLE AND VISUAL ALARMS, D 2. MONTHLY 0.2 GPH TEST [12. MONTHLY 0.2 GPH TEST [13. ANNUAL INTEGRITY TEST(0.1 GPH) [13. ANNUAL INTEGRITY TEST(0.1 GPH) [14. DAILY VISUAL CHECK CONVENTIONAL SUCTION SYSTEMS CONVENTIONAL SUCTION SYSTEMS(Check all that apply) ❑5. DAILY VISUAL MONITORING OF PUMPING SYSTEM+TRIENNIAL PIPING [15. DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM INTEGRITY TEST(0.1 GPH) SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): [16. TRIENNIAL INTEGRITY TEST(0.1 GPH) D 7. SELF MONITORING SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): GRAVITY FLOW D 7. SELF MONITORING [19. BIENNIAL INTEGRITY TEST(0.1 GPH) GRAVITY FLOW(Check all that apply): [18. DAILY VISUAL MONITORING [19. 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) TO POMP SHUT OFF WHEN A LEAK OCCURS D a. AUTO PUMP SHUT OFF WHEN A LEAK OCCURS TO POW SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM D b.AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM WOO-MSCONNECTION DISCONNECTION Oc. NO AUTO PUMP SHUT OFF Oc. NO AUTO PUMP SHUT OFF ❑11. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)WITH FLOW SHUT D 11 AUTOMATIC LEAK DETECTOR OFF OR RESTRICTION ❑12. ANNUAL INTEGRITY TEST(o.l GPH) ❑12.ANNUAL INTEGRITY TEST(0.1 GPH) SUCTION/GRAVITY SYSTEM SUCTION/GRAVITY SYSTEM [113. CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS D 13. CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS EMERGENCY GENERATORS ONLY(Check all that apply) EMERGENCY GENERATORS ONLY(Check all that apply) [114. CONTINUOUS SUMP SENSOR Wn'HOlTT AUTO POMP SHUT OFF [114. CONTINUOUS SUMP SENSOR WITHOUT AU'T'O PUMP SHUT OFF AUDIBLE AND VISUAL ALARMS AUDIBLE AND VISUAL ALARMS [115. AUTOMATIC LINE LEAK DETECTOR (3.0 GPH TEST) WITHOUT FLOW D 15. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST) SHUT OFF OR RESTRICTION [116. ANNUAL INTEGRITY TEST(0.1 GPH) [116.ANNUAL INTEGRITY TEST(0.1 GPH) [117. DAILY VISUAL CHECK D 17.DAILY VISUAL CHECK VIII.DISPENSER CONTAINMENT DISPENSER CONTAINMENT 468, A 1. FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE D 4. DAILY VISUAL CHECK 469. DATEINSTALLED D2. CONTINUOUS DISPENSER PAN SENSOR+AUDIBLE AND VISUAL ALARMS D5. TRENCHILIFNER MONITORING CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR [16. NONE DISPENSER+AUDIBLE AND VISUAL ALARMS D(.OWNER/OPERATOR SIGNATURE I certify that the' fo alit provided herein i ,Agrate to the best of my knowledge. SIGNATURE OF R/OT DATE: SI7/ZOO'I 470. NAME OF OOPERATOR(print): Carlos L. Rodrl U 2 TITLEOFOWNER/OPERATOR: Environ. Compli. Contractor 472' Permit Number(Agency use only) 473 1 Pennit Approved By(Agency use only) 474. 1 Permit Expiration Date(Agency use only) 47s UPCF hwfwrc-b(1/99)-3/4 http://www.unidoes.org Rev.02/16/00