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Wi TFTMD PROGRAM CONSOLIDATED FORM TANKS UNDERGROUND STORAGE T ANKS - TANK PAGE 2 VI.PIPING CONSTRUCTION(Check all t apply) Page of 5 UNDERGROUND PIPING ABOVEGROUND PIPING SYSTEM TYPE ® 1.PRESSURE [:12.SUCTION ❑3.GRAVITY 459 ❑1.PRESSURE [12. SUCTION ❑3.GRAVITY 459 CONSTRUCTION ❑1.SINGLE WALL ❑3.LVED TRENCH ©99.OTHER 460 © 1.SINGLE WALL ❑95.UNKNOWN 462 MANUFACTURER 0 2,DOUBLE WALL ❑95.UNKNOWN ❑2.DOUBLE WALL ❑99.OTHER MANUFACTURER Smith Fiberglass 461 MANUFACTURER 465 ❑1.BARE STEEL ❑6.FRP COMPATIBLE w1100% METHANOL ❑ 1.BARE STEEL ❑6.FRP COMPATIBLE WnoO%METHANOL ❑2.STAINLESS STEEL [17.GALVANIZED STEEL ❑Unknown ❑2. STAINLESS S rEEL ❑7.GALVANIZED STEEL ❑3.PLASTIC COMPATIBLE W/CONTENTS ❑99. Other ❑3. PLASTIC CO ATIBLE W/CONTENTS ©S.FLEXIBLE(HDPE) ❑99. OTHER 0 4.FIBERGLASS [:18.FLEXIBLE(HDPE) ❑4. FIBERGLASS ❑9.CATHODIC PROTECTION [:15.STEEL W/COATING ❑9.CATHODIC PROTECTION 464 1 ❑5. STEEL W/CO TING ©95.UNKNOWN 465 VII.PIPING LEAK DETECTION{Check all that apply) A description of the monitoring ogratn 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): ❑L ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP SHUT ❑1. ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP OFF FOR LEAK,SYSTEM FAILURE,AND SYSTEM DISCONNECTION+ SRUT OFF FOR LEAK,SYSTEM FAILURE,AND SYSTEM DISCONNECTION+ AUDIBLE AND VISUAL ALARMS. AIJDIBLE AND VISUAL ALARMS. ❑2.MONTHLY 0.2 GPH TEST 02. MONTHLY 0.2 GPH TEST ❑3.ANNUAL INTEGRITY TEST(O.1GPH) 0 3.ANNUAL I TEGRTTY TEST(0.IGPH) [:14. D kILY VISUAL CHECK CONVENTIONAL SUCTION SYSTEMS CONVE4TIONAL SUCTION SYSTEMS(Check all that apply) ❑5.DAILY VISUAL MONITORING OF PUMPING SYSTEM+TRIENNIAL PIPING ❑5. D kILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM INTEGRITY TEST(O.1 GPH) SAFE SUCTION SYSTEMS(NO VALUES IN BELOW GROUNDPIPING): ❑6. TRIENNIAL INTEGRrTY TEST(O.1 GPH) ❑7.SELF MONITORING SAFESUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): GRAVITY FLOW ❑7. SELF MONITORING ❑9.BIENNIAL INTEGRITY TEST(0.1 GPH) GRAVITY FLOW(Check all that apply): ❑S. DAILY VISUAL MONITORING [19. B IFNNIAL INTEGRITY TEST(0.1 GPH) SECONDARILY CONTAINED PIPING SECONDARILY CONTAINED PIPING PRESSURIZED PIPING(Check all that apply): PRESS ZED PIPING(Check all that apply): 10. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL 10. COTTWUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL ALARMS AND(Check one) AL ARMS AND(Check one) ❑a. AUTO PUMP SHUT OFF WHEN A LEAK OCCURS ❑ k AUTO PUMP SHUT OFF WHEN A LEAK OCCURS 0 b. AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM ❑ AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM DISCONNECTION DISCONNECTION ❑c. NO AUTO PUMP SHUTOFF Cl( NO AUTO PUMP SHUT OFF ® 11. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)WITH FLOW SHUT ❑ H UTOMATIC LEAK DETECTOR OFF OR RESTRICTION ® 12. ANNUAL INTEGRITY TEST(0.1 GPH) ❑ 12. kNNUAL INTEGRITY TEST(0.1 GPH) SUCTIONIGRAVITY SYSTEM SUCTION/GRAVITY SYSTEM ❑13. CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS 013- ONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS EMERGENCY GENERATORS ONLY(Check all that apply) EMERGENCY GENERATORS ONLY(Check all that apply) [114. CONTINUOUS SUMP SENSOR WITH AUTO PUMP SHUT OFF" [114. ONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF AUDIBLE AND VISUAL ALARMS AUDIBLE AND VISUAL ALARMS ❑ 15. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)WITHOUT FLOW C1 15. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST) SHUT OFF OR RESTRICTION ❑16.ANNUAL INTEGRITY TEST(0.1 GPH) ❑ 16. kNNUAL INTEGRITY TEST(0.1 GPH) ❑17. DAILY VISUAL CHECK ❑17. DAILY VISUAL CHECK VIII.DISPENSER CONTAINMENT DISPENSER CONTAINMENT 0 1.FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE [14.DAILY VISUAL CHECK DATE INSTALLED 469 [12.CONT(NUOUS DISPENSER PP.N SENSOR+AUDIBLE AND VISUAL ALARMS [:15.TRENCH LINER/MONITORING 2003 0 3.CONTINUOUS DISPENSER PAN SENSOR WITH AUTOS OFF FOR ❑6 NONE 4691 DISPENSER+AUDIBLE AND VISUAL ALARMS IX.OWNE R/OPERATOR S IGNATURE I certify that the infomsttion provided herein is Irue and accurate to the best of my knowledge. SIGN E OF OWN OPERAT0 DATE 470 U3 N F OWNERlOPRATOR(pnnt) 411 TITLE OF OWNER/OPERATOR 47,- Permit Number(For local use only) 473 Penrit Approved(For local use only) 474 Permit Expiration Date(For local nse only) 475 UPCF(12199 revised) 12 Formerly SWRCB Form B