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' 'NIFIED PROGRAM CONSOLIDATED FC <br />TANK <br />UNDERGROUND STORAGE TANKS - TANK PAGE 2 <br />VI. PIPING CONSTRUCTION (Check all that apply) Page _ of <br />UNDERGROUND PIPING <br />ABOVEGROUND PIPING <br />SYSTEM TYPE ®1. PRESSURE ❑ 2. SUCTION ❑ 3. GRAVITY 458 <br />❑ 1. PRESSURE ❑ 2. SUCTION ❑ 3. GRAVITY 459 <br />CONSTRUCTION / ❑ 1. SINGLE WALL ❑ 3. LINED TRENCH ❑ 99. OTHER 460 <br />❑ 1. SINGLE WALL ❑ 95. UNKNOWN 462 <br />MANUFACTURER ® 2. DOUBLE WALL ❑ 95. UNKNOWN <br />❑ 2. DOUBLE WALL ❑ 99. OTHER <br />MANUFACTURER Environ 461 <br />MANUFACTURER 463 <br />❑ 1. BARE STEEL ❑ 6. FRP COMPATIBLE w/100% METHANOL <br />❑ 1. BARE STEEL ❑ 6. FRP COMPATIBLE W110094 METHANOL <br />[12. STAINLESS STEEL ❑ 7. GALVANIZED STEEL ❑ UKNOWN <br />❑ 2. STAINLESS STEEL ❑ 7. GALVANIZED STEEL <br />❑ 3. PLASTIC COMPATIBLE W/ CONTENTS ❑ 99. OTHER <br />❑ 3. PLASTIC COMPATIBLE W/ CONTENTS ❑ 8. FLEXIBLE (HDPE) ❑ 99. OTHER <br />® 4. FIBERGLASS ® 8, FLEXIBLE (HDPE) <br />❑ 4. FIBERGLASS ❑ 9. CATHODIC PROTECTION <br />❑ 5. STEEL W/COATING ❑ 9. CATHODIC PROTECTION 464 <br />❑ 5. STEEL W/COATING ❑ 95. UNKNOWN 465 <br />VII. PIPING LEAK DETECTION (Check all that apply) (A description of the monitoring program shall be submitted to the local agency.) <br />UNDERGROUND PIPING <br />ABOVEGROUND PIPING <br />SINGLE WALL PIPING 466 <br />SINGLE WALL PIPING 467 <br />PRESSURIZED PIPING (Check all that apply): <br />PRESSURIZED PIPING (Check all that apply): <br />❑ 1. ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP SHUT OFF FOR <br />❑ 1. ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP SHUT OFF FOR <br />LEAK, SYSTEM FAILURE, AND SYSTEM DISCONNECTION +AUDIBLE AND VISUAL <br />LEAK, SYSTEM FAILURE, AND SYSTEM DISCONNECTION + AUDIBLE AND VISUAL <br />ALARMS. <br />ALARMS. <br />❑ 2. MONTHLY 0.2 GPH TEST <br />❑ 2. MONTHLY 0,2 GPH TEST <br />❑ 3. ANNUAL INTEGRITY TEST (0.1GPH) <br />❑ 3. ANNUAL INTEGRITY TEST (0.1GPH) <br />❑ 4. DAILY VISUAL CHECK <br />CONVENTIONAL SUCTION SYSTEMS <br />CONVENTIONAL SUCTION SYSTEMS (Check all that apply) <br />❑ 5. DAILY VISUAL MONITORING OF PUMPING SYSTEM +TRIENNIAL PIPING INTEGRITY <br />❑ 5. DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM <br />TEST (0.1 GPH) <br />SAFE SUCTION SYSTEMS (NO VALUES IN BELOW GROUNDPIPING): <br />❑ 6. TRIENNIAL INTEGRITY TEST (0.1 GPH) <br />❑ 7. SELF MONITORING <br />SAFE SUCTION SYSTEMS (NO VALVES IN BELOW GROUND PIPING): <br />GRAVITY FLOW <br />E17. SELF MONITORING <br />❑ 9. BIENNIAL INTEGRITY TEST (0.1 GPH) <br />GRAVITY FLOW (Check all that apply): <br />❑ 8. DAILY VISUAL MONITORING <br />[19. BIENNIAL INTEGRITY TEST (0.1 GPH) <br />SECONDARILY CONTAINED PIPING <br />SECONDARILY CONTAINED PIPING <br />PRESSURIZED PIPING (Check all that apply): <br />PRESSURIZED PIPING (Check all that apply): <br />10. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL ALARMS AND <br />10. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL ALARMS AND <br />(Check one) <br />(Check one) <br />❑ a. AUTO PUMP SHUT OFF WHEN A LEAK OCCURS <br />❑ a AUTO PUMP SHUT OFF WHEN A LEAK OCCURS <br />Ob. AUTO PUMP SHUT OFF FOR LEAKS, SYSTEM FAILURE AND SYSTEM <br />❑ b AUTO PUMP SHUT OFF FOR LEAKS, SYSTEM FAILURE AND SYSTEM <br />DISCONNECTION <br />DISCONNECTION <br />❑c. NO AUTO PUMP SHUT OFF <br />❑c NO AUTO PUMP SHUT OFF <br />® 11. AUTOMATIC LINE LEAK DETECTOR (3.0 GPH TEST) WITH FLOW SHUTOFF OR <br />❑ 11. AUTOMATIC LEAK DETECTOR <br />RESTRICTION <br />®12. ANNUAL INTEGRITY TEST (0.1 GPH) <br />❑ 12. ANNUAL INTEGRITY TEST (0.1 GPH) <br />SUCTION/GRAVITY SYSTEM <br />SUCTION/GRAVITY SYSTEM <br />❑ 13. CONTINUOUS SUMP SENSOR +AUDIBLE AND VISUAL ALARMS <br />❑ 13. CONTINUOUS SUMP SENSOR +AUDIBLE AND VISUAL ALARMS <br />EMERGENCY GENERATORS ONLY (Check all that apply) <br />EMERGENCY GENERATORS ONLY (Check all that apply) <br />❑ 14. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF +AUDIBLE AND <br />❑ 14. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF +AUDIBLE AND <br />VISUAL ALARMS <br />VISUAL ALARMS <br />❑ 15. AUTOMATIC LINE LEAK DETECTOR (3.0 GPH TEST) WITHOUT FLOW SHUT OFF OR <br />❑ 15. AUTOMATIC LINE LEAK DETECTOR (3.0 GPH TEST) <br />RESTRICTION <br />❑ 16. ANNUAL INTEGRITY TEST (0.1 GPH) <br />❑ 16. ANNUAL INTEGRITY TEST (0.1 GPH) <br />❑ 17. DAILY VISUAL CHECK <br />❑ 17. DAILY VISUAL CHECK <br />VIII. DISPENSER CONTAINMENT <br />DISPENSER <br />CONTAINMENT ❑ 1. FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE ❑ 4. DAILY VISUAL CHECK <br />DATE INSTALLED 468 ❑ 2. CONTINUOUS DISPENSER PAN SENSOR +AUDIBLE AND VISUAL ALARMS [15. TRENCH LINER / MONITORING <br />1996 03. CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR DISPENSER+ ❑ 6. NONE 469 <br />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/OPERATOR i1� <br />DATE 470 <br />OZ/Lf/,.0- <br />NAME OF OWNER/OPRATOR (print) <br />TITLE OF OWNER/OPERATOR 472 <br />Ian Moorhead <br />Region Gasoline Environmental Compliance Manager <br />local use only) 473 Permit Approved (For local use only) Permit Expiration Date (For local use only) <br />�=m <br />475 <br />UPCF (1/99 revised) Formerly SWRCB Form B <br />