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FF-_ NIFIED PROGRAM CONSOLIDATED F. TANKS UNDERGROUND STORAGE TANK aVl. PINGf�NSTRUCT{O!i"'(EllacRalthatadp►y�-`;� �., � '� _ UNDERGROUND PIPING ABOVEGROUND PIRNG SYSTEM TYPE )if 1 PRESSURE ❑ 2. SUCTION ❑ 3. GRAVITY 111. PRESSURE ❑ 2. SUCTION ❑ 3_ GRAVITY CONSTRUCTIOW ❑ 1. SINGLE WALL ❑ 3. LINED TRENCH ❑99. OTHER ❑ 1. SINGLE WALL ❑95. UNKNOWN MANUFACTURER 5r2. DOUBLE WALL ❑95- UNKNOWN ❑ 2. DOUBLE WALL ❑99. OTHER MANUFACTURER _ CPy,� MANUFACTURER ' ❑ 1.BARE STEEL ❑ 6. FRP COMPATIBLE WI 100%METHANOL ❑ 1. BARE STEEL ❑ 6. FRP COMPATIBLE W/1009.METHANOL MATERIALS AND ❑ 2. STAINLESS STEEL ❑ 7. GALVANIZED STEEL ❑ 2- STAINLESS STEEL ❑ T. GALVANIZED STEEL CORROSION PROTECTION ❑ 3. PLASTIC COMPATIBLE WITH CONTENTS ❑95. UNKNOWN ❑ 3. PLASTIC COMPATIBLE WITH CONTENTS ❑ 6. FLEXIBLE(HDPE) ❑99. OTHER ❑ 4. FIBERGLASS M6. FLEXIBLE(HDPE) 1199. OTHER ❑ 4. FIBERGLASS ❑ 9- CATHODIC PROTECTION f') 5. STEEL WI COATING ❑ 9_CATHODIC PROTECTION ❑ S. STEEL VAP COATING ❑95. UNKNOWN a: r PIPIN IG LEAK DCat Uhe1 -3 )' ✓ `" " £r' c UNDERGROUND PIPING ~ABOVEGROUND PIPING SINGLE WALL PIPINGS06GLE WALL PF4NG PRESSURIZED PIPING(Check allthat appal: PRESSURIZED PIPING(Check Y that apply): - L� 1. ELECTRONIC UNE LEAK DETECTOR 3.0 GPM TEST WITH AUTO PUMP SHUT OFF FOR ❑ 1. ELECTRONIC UNE LEAK DETECTOR 3.0 GPM TEST WITH AUTO PUMP SHUT OFF FOR LEAK, LEAK,SYSTEM FAILURE,AND SYSTEM DISCONNECTION+AUDIBLE AND VISUAL SYSTEM FAILURE,AND SYSTEM DISCONNECTION+AUDIBLE AND VISUAL ALARMS ALARMS ❑ 2. MONTHLY 0.2 GPM TEST _ ❑ 2. MONTHLY 0.2 GPM TEST ❑ 3.ANNUAL INTEGRITY TEST(0.1 GPM) ❑ 3. ANNUAL INTEGRITY TEST(0.1 GPM) ❑ 4. DAILY VISUAL CHECK CONVENTIONAL SUCTION SYSTEMS: CONVENTIONAL SUCTION SYSTEMS(Chock aN OW appty): ❑ 5. DAILY VISUAL MONITORING OF PUMPING SYSTEM+TRIENNIAL PIPING INTEGRITY ❑ S. DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM TEST(0.1 GPM) ❑ 6_ TRIENNIAL INTEGRITY TEST(0.1 GPM) 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 FLOW(Check Y Mal apply): ❑ 9 BIENNIAL INTEGRITY TEST(0.1 GPH) ❑ 6. DAILY VISUAL MONITORING ❑ 9. BIENNIAL INTEGRITY TEST(0.1 GPH) SECONDARILY CONTAINED PIPING SECONDARILY CONTAINED PIPING PRESSURIZED PIPING(Check as Thal apply): PRESSURIZED PIPING(Cheat as Val apply): 10. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL ALARMS AND 10.CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL ALARMS AND(chetic ora) r(Ctheck one) !OI a. AUTO PUMP SHUT OFF NMEN 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 ell AUTOMATIC UNE LEAK DETECTOR 13.0 GPM TEST)WITH FLOW SHUT OFF OR ❑ 11. AUTOMATIC LEAK DETECTOR RESTRICTION ❑ 12. ANNUAL INTEGRITY TEST(0 1 GPH) ❑ 12. ANNUAL INTEGRITY TEST(0.1 GPH) SUCTIONIGRAVITY SYSTEM: SUCTIOWGRAVITY SYSTEM: ❑ 13. CONTINUOUS SUMP SENSOR-AUDIBLE AND VISUAL ALARMS ❑ 13. CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS EMERGENCY GENERATORS ONLY(Check ON V1at apply) EMERGENCY GENERATORS ONLY(Chock a/that applA ❑ 14. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SMUT OFF+AUDIBLE AND ❑ 14. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF+AUDIBLE AND VISUAL VISUAL ALARMS ALARMS ❑ 15. AUTOMATIC LINE LEAK DETECTOR(3.0 GPM TEST)WITHOUT FLOW SHUT OFF OR ❑ 15. AUTOMATIC UNE LEAK DETECTOR(3.0 GPM TEST) RESTRICTION ❑ 16. ANNUAL INTEGRITY TEST 10.1 GPH) ❑ 16. ANNUAL INTEGRITY TEST(0.1 GPM) ❑ 17. DAILY VISUAL CHECK ❑ 17. DAILY VISUAL CHECK VML DISPENSER I:,;0W INAAEl17 DISPENSER CONTAINMENT ❑,/1. FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE C 1. DAILY VISUAL CHECK DATE INSTALLED x^-11 2. CONTINUOUS DISPENSER PAN SENSOR+AUDIBLE AND VISUAL ALARMS ❑ 5. TRENCH LINER/MONITORING 00 L' h.s 3. CONTINPUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR DISPENSER+AUDIBLE AND VISUAL ALARMS ❑ 6. NONE IX OWNERIOPERATOR SIGNATURE I certify that the a p is Irua and of my knaMed". SIGNATOR DATE 01 NAME OF OWNER/OPERATOR(prinQ TITLE OF OWNEROPERATOR M1-n4 .CWrti1r_� Permit Number(For local uss only) Permit Approved(For local use only) Permit Expiration Date(For local use only) I I CUPAFORM(4/99) Formerly SWRCB Form B