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~ dQrED PROGRAM CONSOLIDATED FO O 5 q o TANKS UNDERGROUND STORAGE TANKS-TANK PAGE 2 Pae of VL PIPING CONSTRUCTION(t .k..11 hatwA,) UNDERGROUND PIPING ABOVEGROUND PIPING SYSTEM TYPE 1.PRESSURE ❑2.SUCTION [13-GRAVITY 458- ❑I.PRESSURE ❑2.SUCTION 03-GRAVITY 459. CONSTRUCTION/ ❑1.SINGLE WALL ❑3.LIED TRENCH ❑99-OTHER 460. ❑L SINGLE WALL ❑95.UNKNOWN 462. MANUFACTURER a 2.DOUBLE WALT. ❑95.UNKNOWN ❑?DOUBLE WALL ❑99.OTHER MANUFACTURER 461. MANUFACTURER 463. ❑1.BARE STEEL ❑6.FRP COMPATIBLE W/100%METHANOL ❑L BARE STEEL ❑6.FRP COMPATIBLE W/100%METHANOL ❑2.STAINLESS STEEL ❑7.GALVANIZED STEEL ❑2.STAINLESS STEEL ❑7.GALVANIZED STEEL [13.PLASTIC COMPATIBLE WITH CONTENTS ❑95.UNKNOWN ❑3.PLASTIC COMPATIBLE W/CONTENTS 118.FLEJQBLE(HDPE) ❑99.OTHER 4.FIBERGLASS [18.FLE)aBLE(HDPE) ❑99.OTHER 1 ❑4.FIBERGLASS ❑9.CATHODIC PROTECTION 465. ❑5-STEEL W/COATING ❑9.CATHODIC PROTECTION 464- ❑5-STEEL W/COATING ❑95 UNKNOWN VIL PIPING LEAK DETECTION(rl«x all tmt apply)(A " 'on of8x mwomring progrwn shalt be suboutted to the local agemy.) 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 WITH AUTO PUMP ❑1. ELECTRONIC LBHE LEA DETECTOR 3.0 GPH TEST WITH AUTO PUMP w SHUT-OFF FOR LEAK,SYSTEM FAILURE,A_ND SYSTEM DISCONNECTION SHUT OFF FOR LEAK,SYSTEM EM_AILURE,AND SYSTEM STEM DISCONNECTION +AUDIBLE AND VISUAL ALARMS. +AUDIBLE AND VISUAL ALARMS. ❑2. MONTHLY 02 GPH TEST ❑2. MONTHLY 0.2 GPH TEST I [13. ANNUAL INTEGRITY TEST(0.1 GPH) ❑3. ANNUAL INTEGRITY TEST(0-1 GPI 04. DAILY VISUAL CHECK CONVENTIONAL SUCTION SYSTEMS CONVENTIONAL SUCTION SYSTEMS(Check all that apply) ❑5. DAILY VISUAL MONITORING OF PUMPING SYSTEM+TRIENNIAL PIPING C]5. DAILY VISUALMONTTORING OF PIPING AND PUMPING SYSTEM INTEGRITY TEST(0.1 GPH) SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): [16. TRIENNIAL INTEGRITY TEST(0.1 GPII) ❑7- SELF MONITORING SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): GRAVITY FLOW ❑7. SELF MONITORING [19. BIENNIAL INTEGRITY TEST(0.1 GPH) GRAVITY FLOW(Check all that apply): [18. DAII.Y VISUAL MONITORING ❑9. BIENNIALINTEGRTTYTEST(0.1 GPH) SECONDARILY CONTAINED PIPING SECONDARII.Y CONTAINED PIPING PRESSURIZED PIPING(Check all that apply): PRESSURIZED PIPING(Check all that apply): 10. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL 10. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL ALARMS AND(Check one) ALARMS AND(Check one) a AUTO PUMP SHUT OFF WHEN A LEA OCCURS ❑a.AUTO PUMP SHUT OFF WHEN A LEA OCCURS b.AUTO PUMP SHUT OFF FOR LEAS,SYSTEM FAILURE AND SYSTEM X 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 54 11. AUTOMATIC LINE LEAKDETECTOR(3.0 GPH TEST)WITH FLOW SHUT 11.AUTOMATIC LEA DETECTOR OFF OR RESTRICTION ❑12. ANNUAL INTEGRITY TEST(0.1 GPIs ❑12.ANNUAL INTEGRITY TEST(0-1 GPI SUCTION/GRAVITY SYSTEM SUCTION/GRAVTTY SYSTEM ❑13. CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS pq 13-CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS EMERGENCY GENERATORS ONLY(Check all that apply) EMERGENCY GENERATORS ONLY(Check all that apply) ❑14. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF [114. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF AUDIBLE AND VISUAL ALARMS AUDIBLE AND VISUAL ALARMS ❑15. AUTOMATIC LINE LEA DETECTOR (3.0 GPH TEST) WITH FLOW ❑15-AUTOMATIC LINE LEAKDETECTOR(3.o GpH TEST) SHUT OFF OR RESTRICTION ❑16. ANNUAL INTEGRITY TEST(0.1 GPH) ❑16. ANNUAL INTEGRITY TEST(0.1 GPH) ❑17. DAILY VISUAL CHECK ❑17.DAILY VISUAL CHECK VIII.DISPENSER CONTAINMENT DISPENSER CONTA114MENT 468. ❑1. FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE ❑4. DAILY VISUAL CHECK 469_ DATE INSTALLED J42. CONTINUOUS DISPENSER PAN SENSOR+AUDIBLE AND VISUAL ALARMS ❑5. TRENCH/LINER MONITORING r 3 3 [:13. CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR ❑6. NONE DISPENSER+AUDIBLE AND VISUAL ALARMS DL OWNER/OPERATOR SIGNATURE I certify that the information provided herein is true and accurate to the best of my knowledge. A OF O OP DATE: 470. C! O3 - � 9- 03 472. NAME OF OWNER/OPERATOR(prim): TITLE OF OWNER/OPERATOR CA c � � a � CC /V r A T C) Permit Ntmmber(Agency use only) 473. Permit Approved By(Agency use only) 474_ Permit Expimon Date(Agency use only) 475.