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4 <br />FIED PROGRAM CONSOLIDATED Fl <br />UNDERGROUND STORAGE TANKS - TANK PAGE 2 <br />UNDERGROUND PIPING <br />SYSTEM TYPE X1. PRESSURE ❑ 2. SUCTION [13. GRAVITY <br />CONSTRUCTION ❑ 1. SINGLE WALL ❑ 3. LINED TRENCH ❑ 99. OTHER <br />MANUFACTURER,d2. DOUBLE WALL ❑ 95. UNKNOWN <br />MANUFACTURER A w"'e- r C N <br />❑ 1. BARE STEEL ❑ 6. FRP COMPATIBLE w/l00%. METHANOL <br />❑ 2. STAINLESS STEEL ❑ 7. GALVANIZED STEEL I ❑ Unknown <br />❑ 3. PLASTIC COMPATIBLE W/ CONTENTS ❑ 99. Other <br />)e4. FIBERGLASS ❑ 8. FLEXIBLE (HDPE) <br />[15. STEEL W/COATING ❑ 9. CATHODIC PROTECTION 464 <br />ABOVEGROUND PIPING <br />458 ❑ 1. PRESSURE ❑ 2. SUCTION ❑ 3. GRAVITY <br />460 ❑ 1. SINGLE WALL ❑ 95. UNKNOWN <br />❑ 2. DOUBLE WALL ❑ 99. OTHER <br />461 MANUFACTURER <br />TANK <br />Page _ of _ <br />459 <br />462 <br />463 <br />[11. BARE STEEL <br />❑ 6. FRP COMPATIBLE w/ioD* mmmot, <br />❑ 2. STAINLESS STEEL <br />❑ 7. GALVANIZED STEEL <br />[13. PLASTIC COMPATIBLE W/ CONTENTS <br />❑ 8. FLEXIBLE (HDPE) ❑ 99. OTHER <br />[14. FIBERGLASS <br />❑ 9. CATHODIC PROTECTION <br />❑ 5. STEEL W/COATING <br />❑ 95. UNKNOWN 465 <br />VII. PIPING LEAK DETECTION (Check all that <br />SINGLE WALL PIPING 466 <br />PRESSURIZED PIPING (Check all that apply): <br />❑ 1. ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP SHUT <br />OFF FOR LEAK, SYSTEM FAILURE, AND SYSTEM DISCONNECTION + <br />AUDIBLE AND VISUAL ALARMS. <br />❑ 2. MONTHLY 0.2 GPH TEST <br />❑ 3. ANNUAL INTEGRITY TEST (0.1 GPH) <br />CONVENTIONAL SUCTION SYSTEMS <br />❑ 5. DAILY VISUAL MONITORING OF PUMPING SYSTEM +TRIENNIAL PIPING <br />INTEGRITY TEST (0.1 GPH) <br />SAFE SUCTION SYSTEMS (NO VALUES IN BELOW GROUNDPIPING): <br />❑ 1. SELF MONITORING <br />GRAVITY FLOW <br />❑ 9. BIENNIAL INTEGRITY TEST (0.1 GPH) <br />SECONDARILY CONTAINED PIPING <br />PRESSURIZED PIPING (Check all that apply): <br />10. CONTINUOUS TURBINE SUMP SENSOR WW AUDIBLE AND VISUAL <br />ALARMS AND (Check one) <br />❑ a. AUTO PUMP SHUT OFF WHEN A LEAK OCCURS <br />,db. AUTO PUMP SHUT OFF FOR LEAKS, SYSTEM FAII.URE AND SYSTEM <br />DISCONNECTION <br />❑c. NO AUTO PUMP SHUT OFF <br />11. AUTOMATIC LINE LEAK DETECTOR (3.0 GPH TEST) WITH FLOW SHUT <br />OFF OR RESTRICTION <br />�] 12. ANNUAL INTEGRITY TEST (0.1 GPH) <br />SUCTION/GRAVITY SYSTEM <br />W113. CONTINUOUS SUMP SENSOR + AUDIBLE AND VISUAL ALARMS <br />EMERGENCY GENERATORS ONLY (Check all that apply) <br />❑ 14. CONTINUOUS SUMP SENSOR WITH AUTO PUMP SHUT OFF ` <br />AUDIBLE AND VISUAL ALARMS <br />AUTOMATIC LINE LEAK DETECTOR (3.0 GPH TEST) WITH UT FLOW <br />SHUT OFF OR RESTRICTION <br />❑ 16. ANNUAL. INTEGRITY <br />❑ 17. DAILY VISUAL CHECK <br />DISPENSER CONTAINMENT <br />DATEINSTALLED 468 <br />of the monitoring orogram shall be submitted to the local agency.) <br />SINGLE WALL PIPING 467 <br />PRESSURIZED PIPING (Check all that apply): <br />❑ 1. ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP <br />SHUT OFF FOR LEAK, SYSTEM FAILURE, AND SYSTEM DISCONNECTION + <br />AUDIBLE AND VISUAL ALARMS. <br />❑ 2. MONTHLY 0.2 GPH TEST <br />❑ 3. ANNUAL INTEGRITY TEST (0.1GPH) <br />❑ 4. DAILY VISUAL CHECK <br />CONVENTIONAL SUCTION SYSTEMS (Check all stat apply) <br />❑ 5. DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM <br />❑ 6. TRIENNIAL INTEGRITY TEST (0.1 GPH) <br />SAFE SUCTION SYSTEMS (NO VALVES IN BELOW GROUND PIPING): <br />❑ 7. SELF MONITORING <br />eck <br />GRAVITY FLOW (Chall that apply): <br />[38. DAILY VISUAL MONITORING <br />❑ 9. BIENNIAL INTEGRITY TEST (0.1 GPH) <br />SECONDARILY CONTAINED PIPING <br />PRESSUR17 PIPING (Check all that apply): <br />10. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL <br />ALARMS AND (Check one) <br />❑ a AUTO PUMP SHUT OFF WHEN A LEAK OCCURS <br />❑ b AUTO PUMP SHUT OFF FOR LEAKS, SYSTEM FAILURE AND SYSTEM <br />DISCONNECTION <br />[]c NO AUTO PUMP SHUT OFF <br />[I11. AUTOMATIC LEAK DETECTOR <br />❑ 12. ANNUAL INTEGRITY TEST (0.1 GPH) <br />SUCTION/GRAVITY SYSTEM <br />❑ 13. CONTINUOUS SUMP SENSOR + AUDIBLE AND VISUAL ALARMS <br />EMERGENCY GENERATORS ONLY (Check a8 that apply) <br />❑ 14. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF <br />AUDIBLE AND VISUAL ALARMS <br />[315. AUTOMATIC LINE LEAK DETECTOR (3.0 GPH TEST) <br />TEST (0.1 GPH) I ❑ 16. ANNUAL INTEGRITY TEST (0.1 GPH) <br />❑ 17. DAILY VISUAL CHECK <br />VIII. DISPENSER CONTAINMENT <br />[31. FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE ❑ 4. DAIL <br />�2. CONTINUOUS DISPENSER PAN SENSOR + AUDIBLE AND VISUAL ALARMS ❑ 5. TREN <br />[33. CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR [36. NONE <br />DISPENSER + AUDIBLE AND VISUAL ALARMS <br />UL OWNER/OPERATOR SIGNATURE <br />I certify that the information provided herein is tote and accurate to the best of M kno.ledge. <br />NAME <br />UPCF (1/99 revised) <br />G E /v 7'. <br />Y VISUALCHECK <br />CH LINER / MONITORING <br />40 <br />DATE 4'0 <br />05-- zC� 45,1 - <br />TITLE OF OWNEPJOP =R 4- (r' E /V T472 <br />175 \ Formerly SWRCB Form B <br />