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Ask <br /> IFIED PROGRAM CONSOLIDATED FO <br /> TANKS <br /> UNDERGROUND STORAGE TANKS-TANK PAGE 2 W-9-7-51Phlo- <br /> VI.PIPING CONSTRUCTION(Check all that apply) Page_of <br /> UNDERGROUND PIPING ABOVEGROUND PIPING <br /> SYSTEM TYPE 911.PRESSURE ❑2.SUCTION ❑3.GRAVITY 458 ❑ 1.PRESSURE ❑2. SUCTION [13.GRAVITY 459 <br /> CONSTRUCTION ❑1.SINGLE WALL ❑3.LINED TRENCH [199.OTHER 450 ❑1.SINGLE WALL ❑95.UNKNOWN 462 <br /> MANUFACTURER E(2.DOUBLE WALL ❑95.UNKNOWN ❑2.DOUBLE WALL ❑99.OTHER <br /> MANUFACTURER e Cc;,v-\ 30of& 461 MANUFACTURER 463 <br /> ❑1.BARE STEEL ❑6.FRP COMPATIBLE w/100°�u METHANOL ❑1.BARE STEEL ❑6.FRP COMPATIBLE Whom.METHANOL <br /> ❑2.STAINLESS STEEL ❑7.GALVANIZED STEEL ❑Unknown ❑2. STAINLESS STEEL ❑7.GALVANIZED STEEL <br /> ❑_`3.PLASTIC COMPATIBLE W/CONTENTS ❑99. Other ❑3. PLASTIC COMPATIBLE W/CONTENTS ❑8.FLEXIBLE(HDPE) [199. OTHER <br /> LV'4.FIBERGLASS ❑8.FLEXIBLE(HDPE) [14. FIBERGLASS ❑9.CATHODIC PROTECTION <br /> ❑5.STEEL W/COATING [19.CATHODIC PROTECTION 464 ❑5. STEEL W/COATING [195.UNKNOWN 465 <br /> VII.PIPING LEAK DETECTION(check all thatapply)(A 'ption of the monitoring program shall be submitted to the local agency.) <br /> UNDERGROUND PIPING ABOVEGROUND PIPING <br /> SINGLE WALL PIPING 466 SINGLE WALL PIPING 467 <br /> PRESSURIZED PIPING(Check all that apply): PRESSURIZED PIPING(Check all that apply): <br /> ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP SHUT ❑1. ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP <br /> OFF FOR LEAK,SYSTEM FAILURE,AND SYSTEM DISCONNECTION+ SHUT OFF FOR LEAK,SYSTEM FAILURE,AND SYSTEM DISCONNECTION+ <br /> AUDIBLE AND VISUAL ALARMS. AUDIBLE AND VISUAL ALARMS. <br /> ❑2.MONTHLY 0.2 GPH TEST ❑2. MOMMY 0.2 GPH TEST <br /> [13.ANNUAL INTEGRITY TEST(0.IGPH) [13.ANNUAL INTEGRITY TEST(0.IGPH) <br /> ❑4. DAILY VISUAL CHECK <br /> CONVENTIONAL SUCTION SYSTEMS CONVENTIONAL SUCTION SYSTEMS(Check all that apply) <br /> [15.DAILY VISUAL MONITORING OF PUMPING SYSTEM+TRIENNIAL PIPING ❑5. DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM <br /> INTEGRITY TEST(0.1 GPH) <br /> SAFE SUCTION SYSTEMS(NO VALUES IN BELOW GROUNDPIPING): [16. TRIENNIAL INTEGRITY TEST(0.1 GPH) <br /> [17.SELF MONITORING SAFE$UCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): <br /> GRAVITY FLOW ❑7. SELF MONITORING <br /> ❑9.BIENNIAL INTEGRITY TEST(0.1 GPH) GRAVITY FLOW(Check all that apply): <br /> [18. DAILICVISUAL MONITORING <br /> ❑9. BIENNIAL INTEGRITY TEST(0.1 GPH) <br /> SECONDARILY CONTAINED PIPING SECONDARILY CONTAINED PIPING <br /> PRESSURIZED PIPING(Check all that apply): PRESSURIZED PIPING(Check all that apply): <br /> 10. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL 10. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL <br /> ALARMS AND(Check one) ALARMS AND(Check one) <br /> AUTO PUMP SHUT OFF WHEN A LEAK OCCURS ❑a AUTO PUMP SHUT OFF WHEN A LEAK OCCURS <br /> AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM ❑b AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM <br /> DISCONNECTION DISCONNECTION <br /> ❑c. NO AUTO PUMP SHUT OFF ❑c NO AUTO PUMP SHUT OFF <br /> ❑11. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)WITH FLOW SHUT ❑11. AUTOMATIC LEAK DETECTOR <br /> OFF OR RESTRICTION <br /> ❑12. ANNUAL INTEGRITY TEST(0.1 GPH) ❑ 12. ANNUAL INTEGRITY TEST(0.1 GPH) <br /> SUCTION/GRAVITY SYSTEM SUCTION/GRAVITY SYSTEM <br /> ❑13.CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS ❑13. CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS <br /> EMERGENCY GENERATORS ONLY(Check all that apply) EMERGENCY GENERATORS ONLY(Check all that apply) <br /> ❑14. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF' ❑14. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF' <br /> AUDIBLE AND VISUAL ALARMS AUDIBLE AND VISUAL ALARMS <br /> ❑15. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)WITHOUT FLOW ❑ 15. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST) <br /> SHUT OFF OR RESTRICTION <br /> ❑16.ANNUAL INTEGRITY TEST(0.1 GPH) ❑ 16.ANNUAL INTEGRITY TEST(0.1 GPH) <br /> ❑17. DAILY VISUAL CHECK ❑17. DAILY VISUAL CHECK <br /> VIII.DISPENSER CONTAINMENT <br /> DISPENSER CONTAINMENT ❑I.FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE [14.DAILY VISUAL CHECK <br /> DATE INSTALLED 468 ❑2.CONTINUOUS DISPENSER PAN SENSOR+AUDIBLE AND VISUAL ALARMS ❑5.TRENCH LINER/MONITORING <br /> CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR ❑6.NONE 469 <br /> DISPENSER+AUDIBLE AND VISUAL ALARMS <br /> IX.OWNER/OPERATOR SIGNATURE <br /> I certify that the information provided herein is true and accurate to the best of my knowledge. _ <br /> SIGNATURE OF�OWNER/OPE /17 DATE 470 <br /> NAME OF OWNER/OPRATOR(print) 471 TITLE OF OWNER/OPERATOR <br /> Permit Numher(For local use only) n Permit Approved(For local use only) 474 Permit Expiration Date(For local use only) 475 <br /> UPCF(12/99 revised) 12 Formerly SWRCB Form B <br />