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tqPIED PROGRAM CONSOLIDATED FOIq TANKS UNDERG ROUND STORAGE TANKS - TANK PAGE 2 0' VI.PIPING CONST'RUCTJON(Checkall that apply),:: UNDERGROUND PIPING ABOVEGROUND PIPING SYSTEM TYPE ®1.PRESSURE ❑2.SUCTION ❑3.GRAVITY 458. ❑1.PRESSURE ❑2.SUCTION ❑3.GRAVITY 459. CONSTRUCTION/ ❑1.SINGLE WALL ❑3.LINED TRENCH ❑99.OTHER 460. ❑1.SINGLE WALL ❑95.UNKNOWN 462. MANUFACTURER ®2 DOUBLE WALL ❑95.UNKNOWN ❑2.DOUBLE WALL ❑99.OTHER MANUFACTURER 461. MANUFACTURER 463. ❑1.BARE STEEL ❑6.FRP COMPATIBLE W/100%METHANOL ❑I.BARE STEEL ❑6.FRP COMPATIBLE W/100%METHANOL ❑2.STAINLESS STEEL ❑7.GALVANIZED STEEL ❑2.STAINLESS STEEL ❑7.GALVANIZED STEEL ❑3.PLASTIC COMPATIBLE WITH CONTENTS ❑95.UNKNOWN ❑3.PLASTIC COMPATIBLE W/CONTENTS ❑8.FLEXIBLE(HDPE) ❑99.OTHER ❑4.FIBERGLASS ®8.FLEXIBLE(HDPE) ❑99.OTHER ❑4.FIBERGLASS ❑9.CATHODIC PROTECTION ❑5.STEEL W/COATING ❑9.CATHODIC PRO"IT:CTION 464. ❑5.STEEL W/COATING ❑95.UNKNOWN 465. VEL.PIPING LEAK DETECTION,(chcckall thaia ply)(Adescri tion ofthe inonitpring pro shall be submitted tothelocal age icy) UNDERGROUND PIPING ABOVEGROUND PIPING SINGLE WALL,PIPING 466. SINGLE WALL,PIPING 467. PRF,SSURIZED PIPING(Check all that apply): PRESSURIZED PIPING(Check all that apply): ❑1. ELECTRONIC LINE LEAK DETECTOR 3.0 GPM TEST WITH AUTO PUMP ❑1. ELECTRONIC LINE LEAK DETECTOR 3.0 GPM 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. ❑2. MONTHLY 0.2 GPM TEST ❑2. MONTHLY 0.2 GPM TEST [13. ANNUAL INTEGRITY TEST(0.1 GPH) ❑3. ANNUAL INTEGRITY TEST(0.1 GPM) [14. DAILY VISUAL CHECK CONVENTIONAL SUCTION SYSTEMS CONVENTIONAL SUCTION SYSTEMS(Check all that apply) ❑5. DAILY VISUAL MONITORING OF PUMPING SYSTEM+TRIENNIAL PIPING ❑5. DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM INTEGRITY TEST(0.1 GPM) SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): [16. TRIENNIAL INTEGRITY TEST(0.1 GPM) [17. SELF MONITORING SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): GRAVITY FLOW ❑7. SELF MONITORING [19. BIENNIAL INTEGRITY TEST(0.1 GPM) GRAVITY FLOW(Check all that apply): [18. DAILY VISUAL MONITORING [19. BIENNIAL INTEGRITY TEST(0.1 GPM) 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) ❑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 ❑c. NO AUTO PUMP SHUT OFF ❑c. NO AUTO PUMP SHUT OFF 011. AUTOMATIC LINE LEAK DETECTOR(3.0 GPM TEST)WITH FLOW SHUT ❑11 AUTOMATIC LEAK DETECTOR OFF OR RESTRICTION ® 12. ANNUAL INTEGRITY TEST(0.1 GPM) [112. ANNUAL INTEGRITY TEST(0.1 GPM) SUCTION/GRAVITY SYSTEM SUCTION/GRAVITY SYSTEM ❑13. CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS ❑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 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 GPM TEST) WITHOUT FLOW [115. AUTOMATIC LINE LEAK DETECTOR(3.0 GPM TEST) SHUT OFF OR RESTRICTION ❑16. ANNUAL INTEGRITY TEST(0.1 GPM) ❑16. ANNUAL INTEGRITY TEST(0.1 GPM) ❑ 17. DAILY VISUAL CHECK ❑ 17. DAILY VISUAL CHECK VIII DISPENSF,R('ON'CAINMEN,r DISPENSER CONTAINMENT 48 ❑I. FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE ❑4. DAILY VISUAL CHECK 469. DATE INSTALLED [12. CONTINUOUS DISPENSER PAN SENSOR+AUDIBLE AND VISUAL ALARMS ❑5. TRENCH/LINER MONITORING 2002,March 03. CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR ❑6. NONE DISPENSER+AUDIBLE AND VISUAL ALARMS IX.OWNER/OPERATOR SIGNATURE, I certify that the information ovided herein is true and accurate to the best of my knowledge. SIGNATURE OF OWNI;Rh�,YFATOR DATE: 470 NAME OF OWNER/OP MATOR(print): SAFEWAY INC. TITLE OF OWNERIOPERATOR: �_ ♦ !!;Oz"t- 47z. Permit Number(Agency use only) _77C__-1 Approved By(Agency use only) 474. 1 Permit Expiration Date(Agency use only) 475. UPCF hwfwrc-h(1/99)-3/4 htip://www.uni(locs.org Rev.02/16/00