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Uf IED PROGRAM CONSOLIDAT FORM SITE #255886/5886 TANKS UNDERGROUND STORAGE TANKS - TANK PAGE 2 VI.PIPING CONSTRUCTION(Check all that apply) Page of UNDERGROUND PIPING ABOVEGROUND PIPING SYSTEM TYPE 01.PRESSURE ❑2.SUCTION ❑3.GRAVITY 458 ❑l.PRESSURE ❑2.SUCTION ❑3.GRAVITY 459 1711.SINGLE WALL [:13.LINED TRENCH ❑99.OTHER 460 [11.SINGLE WALL ❑95.XERXES 462 CONSTRUCTION/ ®2.DOUBLE WALL ❑95.XERXES ❑2.DOUBLE WALL ❑99.OTHER MANUFACTURER MANUFACTURER _ 461 MANUFACTURER 463 ❑1.BARE STEEL ❑6.FRP COMPATIBLE wi rom METHANOL Eli.BARE STEEL E16.FRP COMPATIBLE W/100%METHANOL MATERIALS AND E12.STAINLESS STEEL El 7.GALVANIZED STEEL E12.STAINLESS STEEL [17.GALVANIZED STEEL CORROSION EI 3.PLASTIC COMPATIBLE WITH CONTENTS E195.XERXES E13.PLASTIC COMPATIBLE WITH CONTENTS 08.FLEXIBLE(HDPE) [199.OTHER PROTECTION ®4.FIBERGLASS ❑8.FLEXBLE(HDPE) 099.OTHER ❑4. FIBERGLASS ❑9.CATHODIC PROTECTION El 5.STEEL W/COATING ❑9.CATHODIC PROTECTION 464 El 5. STEEL W/COATING ❑95. XERXES 465 VII.PIPING LEAK DETECTION(Check all that apply)(A description of the monitoring program shall be submitted to the local agency.) UNDERGROUND ABOVEGROUND PIPING SINGLE WALL PIPING 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 WITH AUTO PUMP SHUT OFF FOR ❑ 1. ELECTRONIC LINE LEAK DETECTOR 3.0 GPH 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 GPH TEST ❑ 2.MONTHLY 0.2 GPH TEST ❑ 3.ANNUAL INTEGRITY TEST(0.1 GPH) ❑ 3.ANNUAL INTEGRITY TEST(0.1 GPH) ❑ 4.DAILY VISUAL CHECK CONVENTIONAL SUCTION SYSTEMS(Check all that apply): CONVENTIONAL SUCTION SYSTEMS: F-15 DAILY VISUAL MONITORING OF PUMPING SYSTEM+TRIENNIAL PIPING INTEGRITY El 5. DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM TEST(0.1 GPH) ❑ 6.TRIENNIAL INTEGRITY TEST(0.1 GPH) 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 all that apply): ❑ 9. BIENNIAL INTEGRITY TEST(0.1 GPH) ❑ 8.DAILY VISUAL MONITORING ❑ 9.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 WITH AUDIBLE AND VISUAL ALARMS AND(check one) 10. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL ALARMS AND ❑ a.AUTO PUMP SHUT OFF WHEN A LEAK OCCURS (Check one) ❑ a.AUTO PUMP SHUT OFF WHEN A LEAK OCCURS ❑ b.AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM DISCONNECTION ® b.AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM F1 c.NO AUTO PUMP SHUT OFF DISCONNECTION ❑ i I.AUTOMATIC LEAK DETECTOR ❑ c.NO AUTO PUMP SHUT OFF ❑ 12.ANNUAL INTEGRITY TEST(0.1 GPH) ® 11.AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)WITH FLOW SHUT OFF OR SUCTION/GRAVITY SYSTEM: RESTRICTION ® 12.ANNUAL INTEGRITY TEST(0.1 GPH) ❑ 13.CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS SUCTION/GRAVITY SYSTEM: EMERGENCY GENERATORS ONLY(Check aUthat apply) ❑ 13.CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS ❑ 14.CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF+AUDIBLE AND VISUAL ALARMS EMERGENCY GENERATORS ONLY(Check aQ that apply) ❑ 15.AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST) ❑ 14. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF+AUDIBLE AND VISUAL ALARMS ❑ 16.ANNUAL INTEGRITY TEST(0.1 GPH) ❑ 15.AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)WITH FLOW SHUT OFF OR ❑ 17. DAILY VISUAL CHECK RESTRICTION ❑ 16.ANNUAL INTEGRITY TEST(0.1 GPH) ❑ 17. DAILY VISUAL CHECK VM.DISPENSER CONTAINMENT DISPENSER CONTAINMENT ❑ 1.FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE ❑ 4.DAILY VISUAL CHECK DATE INSTALLED 468 ❑ 2.CONTINUOUS DISPENSER PAN SENSOR+AUDIBLE AND VISUAL ALARMS ❑ 5.TRENCH LINER/MONITORING 1995 ❑ 3.CONTINUOUS DISPENSER PAN SENSOR WITII AUTO SHUT OFF FOR DISPENSER+AUDIBLE AND VISUAL ALARMS ❑ 6.NONE 469 IX.OWNER/OPERATOR SIGNATURE I certify that the information provided herein is true and accurate to the best of my knowledge. SIGNATURE OF OWNER/OPERATOR DATE 470 04/07/03 NAME OF OWNER/OPERATOR(print) 471 TITLE OF OWNER/OPERATOR 472 SONIA RAY COMPLIANCE SPECIALIST Permit Number(For local use only) 473 Permit Approved(Por local use only) 474 1 Permit Expiration Date(For local use only)475