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IED PROGRAM CONSOLIDATED` TANK UNDERGROUND STORAGE TANKS -TANK PAGE 2 VI.PIPING CONSTRUCTION(check on that ) Paga-'of UNDERGROUND PIPING ABOVEGROUND PIPING SYSTEM TYPE X1.PRESSURE [12.SUCTION [33.GRAVITY 458 ❑1.PRESSURE ❑2. SUCTION ❑3.GRAVITY 459 CONSTRUCTION [31.SINGLE WALL ❑3.LINED TRENCH ❑99.OTHER 460 ❑1.SINGLE WALL [395.UNKNOWN 462 MANUFACTURER)<2.DOUBLE WALL [395.UNKNOWN [32.DOUBLE WALL ❑99.OTHER MANUFACTURER A M E A O 461 MANUFACTURER 463 ❑1.BARE STEEL ❑6.FRP COMPATIBLE w/100% METHANOL [31.BARE STEEL [36.FRP COMPATIBLE W/1om METHANOL [32.STAINLESS STEEL ❑7.GALVANIZED STEEL I ❑Unknown [32. STAINLESS STEEL [37.GALVANIZED STEEL [33.PLASTIC COMPATIBLE W/CONTENTS ❑99. Other [33. PLASTIC COMPATIBLE W/CONTENTS [38.FLEXIBLE(HDPE) ,Q 99. OTHER Ix 4.FIBERGLASS [38.FLEXIBLE(HDPE) [34. FIBERGLASS ❑9.CATHODIC PROTECTION [35.STEEL W/COATING [39.CATHODIC PROTECTION 464 [35. STEEL W/COATING E395.UNKNOWN 465 VIL PIPING LEAK DETECTION(Check a0 that lyi(Ade' ' ion of the inonito' am 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): ❑1.ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST FEW AUTO PUMP SHUT ❑1. ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP OFF FOR LEAK,SYSTEM FAILURE,AND SYSTEM DISCONNECTION+ SHUT OFF FOR LEAK,SYSTEM FAILURE,AND SYSTEM DISCONNECTION+ AUDIBLE AND VISUAL ALARMS. AUDIBLE AND VISUAL ALARMS. [32.MONTHLY 0.2 GPH TEST ❑2. MONTHLY 0.2 GPH TEST ❑3.ANNUAL INTEGRITY TEST(0.1GPH) ❑3.ANNUAL INTEGRITY TEST(O.1GPH) [34. DAILY VISUAL CHECK CONVENTIONAL SUCTION SYSTEMS CONVENTIONAL SUCTION SYSTEMS(Check all that apply) 0 5.DAILY VISUAL MONITORING OF PUMPING SYSTEM+TRIENNIAL PIPING INTEGRITY TEST(0.1 GPH) 5. DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM SAFE SUCTION SYSTEMS(NO VALUES IN BELOW GROUNDPIPING): [36. TRIENNIAL INTEGRITY TEST(0.1 GPH) [37.SELF MONITORING SAFE SUCTION 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): ❑8. DAILY VISUAL MONITORING [39. BIENNIAL INTEGRITY TEST(0.1 GPH) SECONDARILY CONTAINED PIPING SECONDARILY CONTAINED PIPING PRESSURIZED PIPING(Check all that apply): PRESSURIZED PIPING(Check all that apply): 10. CONTINUOUS TURBINE SUMP SENSOR WI1' AUDIBLE AND VISUAL 10. CONTINUOUS TURBINE SUMP SENSOR WITE AUDIBLE AND VISUAL ALARMS AND(Check oro) ALARMS AND(Cluck one) Xa. AUTO PUMP SHUT OFF WHEN A LEAK OCCURS :JJ C Q IV ❑a AUTO PUMP SHUT OFF WHEN A LEAK OCCURS ❑b. AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM ❑b AUTO PUMPSHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM DISCONNECTION DISCONNECTION ❑c. NO AUTO PUMP SHUT OFF ❑c NO AUTO PUMP SHUT OFF X11. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)WITH FLOW SHUT ❑11. AUTOMATIC LEAK DETECTOR OFF OR RESTRICTION ❑12. ANNUAL INTEGRITY TEST(0.1 GPH) ❑12. ANNUAL INTEGRITY TEST(0.1 GPH) SUCTION/GRAVITY SYSTEM SUCTION/GRAVITY SYSTEM ❑13. CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS [313. CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS EMERGENCY GENERATORS ONLY(Check all that apply) EMERGENCY GENERATORS ONLY(Check all that apply) [314. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF* ❑14. CONTINUOUS 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 SHUT OFF OR RESTRICTION [315. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST) ❑16.ANNUAL INTEGRITY TEST(0.1 GPH) ❑16.ANNUAL INTEGRITY TEST(0.l GPH) E317. DAILY VISUAL CHECK ❑17. DAILY VISUAL CHECK VIII.DISPENSER CONTAINMENT DISPENSER CONTAINMENT ❑1.FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE E34.DAILY VISUAL CHECK DATE INSTALLED 468 [32.CONTINUOUS DISPENSER PAN SENSOR+AUDIBLE AND VISUAL ALARMS ❑5.TRENCH LINER/MONITORING ❑3.CONTINUOUS DISPENSER PAN SENSORIST AUTO SHUT OFF FOR DISPENSER+AUDIBLE AND VISUAL ALARMS •NONE 469 IX.OWNER/OPERATOR SIGNATURE I certify that the Wbrtnntion provided hetein is true and accurate to the best of my knowledge. SIGNATURE OF OWNER/OPERATOR DATE 05--A4-0+' 470 N NAME OF OWNER/OPRATOR(print) TITLE OF OWNER/OPERATOR 472 C'1< Co J 7 1 s4 e5 Mn� UPCF(1/99'revised) 175 Formerly SWRCB Form B