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La.1FIED PROGRAM CONSOLIDATED FO),.,, TANKS UNDERGROUND STORAGE TANKS - TANK PAGE 2 VI.PIPING CONSTRUCTION(check all that apply) Page_of_ UNDERGROUND PIPING ABOVEGROUND PIPING SYSTEM TYPE N 1.PRESSURE ❑2.SUCTION ❑3.GRAVITY 458 ❑1.PRESSURE [12. SUCTION 0 3.GRAVITY 459 CONSTRUCTION ❑1.SINGLE WALL ❑3.LINED TRENCH ❑99.OTHER 450 0 1.SINGLE WALL [195.UNKNOWN 462 MANUFACTURER ®2.DOUBLE WALL ❑95.UNKNOWN [12.DOUBLE WALL 099.OTHER MANUFACTURER 461 MANUFACTURER 463 ❑1.BARE STEEL ❑6.FRP COMPATIBLE w/IW% METHANOL. [11,BARE STEEL 0 6.FRP COMPATIBLE W/100x METHANOL ❑2.STAINLESS STEEL O 7.GALVANIZED STEEL 0 Unknown 0 2. STAINLESS STEEL 0 7.GALVANIZED STEEL ❑3.PLASTIC COMPATIBLE W/CONTENTS ®99. Other [J3. PLASTIC COMPATIBLE W/CONTENTS 0 8.FLEXIBLE(HDPE) [199. OTHER 0 4.FIBERGLASS ❑8.FLEXIBLE(HDPE) [14. FIBERGLASS ❑9.CATHODIC PROTECTION ❑5.STEEL W/COATING ❑9.CATHODIC PROTECTION 464 [15. STEEL W/COATING ❑95.UNKNOWN 465 VIL PIPING LEAK DETECTION(Check all that 1)(A dee Kion ofthe monitoring program shall be suborned w the local eno.) UNDERGROUND PIPING ABOVEGROUND PIPING SINGLE WALL PIPING 466 SINGLE WALL PIPING 467 PRESSURIZED PIPING(Check ell that apply): PRESSURIZED PIPING(Check W tlut apply): ❑1.ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP SHUT 0 1. ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP 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. ❑2.MONTHLY 0.2 GPH TEST Cl 2. MONTHLY 0.2 GPH TEST 0 3.ANNUAL INTEGRITY TEST(0.IGPH) 0 3.ANNUAL INTEGRITY TEST(0.IGPH) 04. DAILY VISUAL CHECK CONVENTIONAL SUCTION SYSTEMS CONVENTIONAL SUCTION SYSTEMS(Check all that apply) 0 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 VALUES IN BELOW GROUNDPIPING): 0 6. TRIENNIAL INTEGRITY TEST(0.1 GPH) [17.SELF MONITORING SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): GRAVITY FLOW 07. SELF MONITORING 0 9.BIENNIAL INTEGRITY TEST(0.1 GPH) GRAVITY FLOW(Check all that apply): 08. DAILY VISUAL MONITORING 0 9. BIENNIAL INTEGRITY TEST(0.1 GPH) SECONDARILY CONTAINED PIPING SECONDARILY CONTAINED PIPING PRESSURIZED PIPING(Check.11 thn apply): PRESSURIZED PIPING(Cheek all that apply): 10. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL 10. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL ALARMS AND(Check our) ALARMS AND(Check one) ❑a. AUTO PUMP SHUT OFF WHEN A LEAK OCCURS ❑a AUTO PUMP SHUT OFF WHEN A LEAK OCCURS ❑ It. AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM ❑b AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM DISCONNECTION DISCONNECTION Oc. NO AUTO PUMP SHUT OFF Oc NO AUTO PUMP SHUT OFF 0 11. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)WITH FLOW SHUT O 11 AUTOMATIC LEAK DETECTOR OFF OR RESTRICTION [112. ANNUAL INTEGRITY TEST(0.1 GPH) 0 12. ANNUAL INTEGRITY TEST(0.1 GPH) 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 an that apply) 0 14. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF• [314. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUTOFF AUDIBLE AND VISUAL ALARMS AUDIBLE AND VISUAL ALARMS [115. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)WITHOUT FLOW 0 15. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST) SHUT OFF OR RESTRICTION 0 16.ANNUAL INTEGRITY TEST(0.1 GPH) 0 16.ANNUAL INTEGRITY TEST(0.1 GPH) 017. DAILY VISUAL CHECK 017. DAILY VISUAL CHECK VIII.DISPENSER CONTAINMENT DISPENSER CONTAINMENT ❑1.FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE [14.DAILY VISUAL CHECK DATE INSTALLED 468 0 2.CONTINUOUS DISPENSER PAN SENSOR+AUDIBLE AND VISUAL ALARMS 0 5.TRENCH LINER/MONITORING [13.CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR [16.NONE 469 DISPENSER+AUDIBLE AND VISUAL ALARMS IN.OWNER/OPERATOR SIGNATURE 1 arty that the mf x m provided hatain a tme atM accurate to the beat ofmy krmwlolse. SIGNATUREO ER/ PERATOR DATE a]o NAME OF ER/OPRATOR(print) 471 1 TITLE OF OWNS OPERATOR 472 Andrew E.Cullen Director Envimmental Service Pnmit Number(For local use only) 473 Permit Apprvv (For local um only) 474 Patted E pkatwn Date(For local use only) 475 UPCF(12/99 revised) 12 Formerly SWRCB Form B i