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IIFIEO PROGRAM CONSOLIDATED FC I( TANKS I UNDERGROUND STORAGE TANKS - TANK PAGE 2 I A.PIPING CONSTRUCTION(Check ad mar aopy) UNDERGROUND PIPING ! ABOVEGROUND PIPING SYS-Mt P`- 1,�(, PRESSURE _. SUC7ICN ❑ 7. 3RAVITY'C PPESSURE _ SUCTION ❑ 3. URAVITY CONSTRUCTION/ ❑ 1. SINGLE'NALL .� 3 JNED TRENCH ❑99. OTHER ❑ 1. SINGLE NALL ❑95 UNKNOWN MANUFACTURER ��, DOUBLE WALL ❑95. UNKNOWN ❑ 2. DOUBLE WALL ❑99. OTHER MANUFACTURER `l I✓l 1-k ✓ MANUFACTURE.R C1 '.3ARE STEEL I 5. PRP-OMPATIBLE'M 100%METHANOL ❑ I 3ARE STEEL ❑ i. PRP COMP4,11BLE'N/'00%ME7HANOL MATERIALS AND ❑ 2. STAINLESS STEEL ❑ 7. GALVANIZED STEEL ❑ ? STAINLESS STEEL ❑ 7. GALVANIZED STEEL CORROSION PROTECTION ❑ 3. PLASTIC COMPATIBLE'MTH CONTENTS ❑45. UNKNOWN ❑ 3. PLASTIC OCMPATIBLE WTH CONTENTS ❑ 3. FLEXIBLE(HDPE) ❑39. OTHER ❑ 4. FIBERGLASS ❑ i. F L.EXIBLE(HOPE/ ❑99. OTHER C 4. --IBERGLASS ❑ 9. -::ATHOOIC PROTECTION ❑ 5. STEEL'N/COATING 3. CATHODIC PROTECTION ❑ 5. S.cEL'Nt COATING ❑95. UNKNOWN VII.PIPING LEAK DETECTION(Cheat ad that aoply) JNOERGROUNO PIPING ABOVEGROUND PIPING SINGLE WALL PIPING SINGLE WALL PIPING PRESSURIZED PIPING(Check all that ao^: PRESSURIZED PIPING lChear ad that aaoM: ❑ ELECTRONIC LINE LEAK DETECTOR 3.0 GPM TEST WITH AUTO PUMP SHUT OFF FOR ❑ 1. ELECTRONIC UNE LEAK OETECTOR 3.0 GPM TEST'MTH AUTO PUMP SHUT OFF FOR LEAK. LEAK,SYSTEM FAILURE.AND SYSTEM OISCONNECTION•AUDIBLE AND VISUAL SYSTEM FAILURE.AND SYSTEM DISCONNECTION-AUOIBLE AND VISUAL ALARMS ALARMS !❑ Z. MONTHLY 0.2 GPM TEST ❑ 2. MONTHLY 0.2 GPM TEST i❑ 3. ANNUAL:NTEGRITY EST(0.1 GPM) ❑ 3. ANNUAL INTEGRITY TEST(0.1 GPM) ❑ 4. DAILY VISUAL CHECK CONVENTIONAL SUCTION SYSTEMS: CONVENTIONAL SUC70N SYSTEMS(Cheat as that aopyl: ❑ S. DAILY VISUAL MONITORING OF PUMPING SYSTEM-TRIENNIAL PIPING INTEGRITY ❑ o. DAILY VISUAL MONITORING OF PIPING AND PUMPING SYS cM j `EST(0.1 GPM) ❑ 5. 'BIENNIAL INTEGRITY EST 10.1 GPM) ' I SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): ❑ 7 SELF MONITORING ❑ 7. SELF MONITORING GRAVITY FLOW. GRAVITY ROW(Clock aM mat aoplv): ❑ 4. 31ENNIAL INTEGRITY TEST(0./GPM) I❑ 3. DAILY VISUAL.MONITCRING j❑ 4. 31ENNtAL:NTEGRITY-EST.i0.1 GPM) SECONDARILY CONTAINED PIPING ` SECONDARILY CONTAINED PIPING PRESSURIZED PIPING(Check ail that aoptv): PRESSURIZED PIPING f Cheat ad that aoPM: '0. ^ONTINUOUS TURBINE SUMP SENSOR'MTH AUDIBLE AND VISUAL ALARMS AND 'O.CONTINUOUS 7URSINE SUMP SENSOR'MTH AUDIBLE AND VISUAL ALARMS AND Icneck one) Check one) ❑ a. AUTO PUMP SHUT CFF`NHEN A LEAK OCCURS ❑ a. AUTO PUMP SHUT OFF WHEN A LEAK OCCURS I ❑ 5. AUTO PUMP SHUT OFF FOR LEAKS.SYSTEM FAILURE AND SYSTEM I❑ o. AUTO PUMP SHUT OFF FCR LEAKS.SYSTEM FAILURE AND SYSTEM DISCONNECTION DISCONNECTION c. NO AUTO PUMP SHUT OFF ❑ .NO AUTO PUMP SHUT OFF ! �t I Ti. AUTOMATIC UNE LEAK DETECTOR(3.0 GPM TEST)WITH FLOW SHUT OFF OR I❑ 11. AUTOMATIC LEAK CE EC-OR RESTRICTION ❑ 12. ANNUAL INTEGRITY TEST(0.1 GPM) ❑ 2. ANNUAUNTEGRITY EST(0.1 GRH) f SUCTION/GRAVITY SYSTEM: SUCTION/GRAVITY SYSTEM: ❑ '3. CONTINUOUS SUMP SENSOR-AUDIBLE AND VISUAL ALARMS ❑ 13. CONTINUOUS SUMP SENSOR-AUDIBLE-AND VISUAL ALARMS EMERGENCY GENERATORS ONLY(Check ad that appy) EMERGENCY GENERATORS ONLY(Check as that apply) ❑ 14 CONTINUOUS SUMP SENSOR'MTHOUT AUTO PUMP SHUT OFF-AUDIBLE AND ❑ 1e. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF-AUDIBLE AND VISUAL VISUAL ALARMS ALARMS ❑ 15. AUTOMATIC UNE LEAK DETECTOR 13.0 GPM TEST)WITHOUT FLOW SHUT OFF OR ❑ 15. AUTOMATIC UNE LEAK DETECTOR(3.0 GPM TEST) RESTRICTION ❑ 'S. ANNUAL INTEGRITY TEST(0.1 GPH) I❑ 15. ANNUAL INTEGRITY TEST(0.1 GPM) C 7. 'DAILY VISUAL CHECK !❑ '7. DAILY VISUAL CHECK VIII.DISPENSER CONTAINMENT DISPENSER CONTAINMENT ❑�'• FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE ❑ 4. DAILY VISUAL CHECK DAT c INSTALLED -1 3 2. CONTINUOUS DISPENSER PAN SENSOR-AUDIBLE AND VISUAL ALARMS ❑ 5. TRENCH LINER/MONITORING ❑ 3. CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR DISPENSER+AUDIBLE AND VISUAL ALARMS ❑ 5. NONE IX.OWNER/OPERATOR SIGNATURE 1 Comfy that the rfof ailon oroviaea hemin is true ana accurate to the oast of my knomeage. SIGNATURE OF OWNER/OPERATOR DATE I NAME OF OWNER/OPERATCR;pnnt) I TITLE OF CWNER/OPERATOR ?Ymil Numoer tForlocal use only) �Mmt ADprovea IFOr logl use on/Vl I ?!rihll txoIratlan Bate(For iocat use onry) CUPAFORM(4/99) Formerly SWRCB Forth 5