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IFIED PROGRAM CONSOLIDATED REM SITE#255417/5417 TANKS UNDERGROUND STORAGE TANKS - TANK PAGE 2 VI.PIPING CONSTRUCTION(CheckaUthatapply) Pie of UNDERGROUNDUNI)ERGROUND PIPING ABOVEGR UND PIPIN SYSTEM TYPE ®1.PRESSURE ❑2.SUCTION 3.GRAVITY 458 [11.PRESSURE ❑2.SUCTION 03.GRAVITY 459 ❑1.SINGLE WALL [13.LINED TRENCH [199,OTHER 460 [11.SINGLE WALL ❑95.XERXES 462 CONSTRUCTION/ ®2.DOUBLE WALL ❑95.XERXES ❑2.DOUBLE WALL [199.OTHER MANUFACTURER MANUFACTURER461 MANUFACTURER 463 El _ I.BARE STEEL 6.FRP COMPATIBLE wi;;%METHANOL [11.BARE STEEL 06.FRP COMPATIBLE W/100%METHANOL MATERIALS AND 112.STAINLESS STEEL ❑7.GALVANIZED STEEL 02.STAINLESS STEEL ❑7.GALVANIZED STEEL CORROSION 113.PLASTIC COMPATIBLE WITH CONTENTS 095.XERXES 03.PLASTIC COMPATIBLE WITH CONTENTS 08.FLEXIBLE(HDPE) 099.OTHER PROTECTION ®4.FIBERGLASS ❑8.FLEXIBLE(HDPE) 099.OTHER 04. FIBERGLASS 09.CATHODIC PROTECTION 5.STEEL W/COATING 09.CATHODIC PROTECTION 464 105. STEEL W/COATING 95. XERXES 465 VII.PIPING LEAK DETECTION(Check all dmt apply)(A description of the mmaitoringprogram shall be submitted to the local agency.) NDER R UND PIPING ABOVEGROUND PIPIN 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 SMS ❑ 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: ❑ 5 DAILY VISUAL MONITORING OF PUMPING SYSTEM+TRIENNIAL PIPING INTEGRITY ® 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(O.1 GPH) SECONDARILY CONTAINED PIPING SECONDARILY CONTAINED PIPING PRESSURIZED PIPING(Check all that apply): PRESSURIZED PIPING(Check all that apply): f0.CONTINUOUS TURBINE SUMP SENSORI AUDIBLE AND VISUAL ALARMS AND 10.CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL AND(check one) (Check one) ❑ a AUTO PUMP SHUT OFF WHEN A LEAK OCCURS ❑ 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 ❑ c.NO AUTO PUMP SHUT OFF DISCONNECTION ❑ 11.AUTOMATIC LEAK DETECTOR ❑ c.NO AUTO PUMP SHUT OFF ❑ 12.ANNUAL INTEGRITY TEST(0.1 GPH) ® i I.AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)wrm FLOW SHUT OFF OR RESTRICTION SUCTION/GRAVITY SYSTEM ® 12. ANNUAL INTEGRITY TEST(0.1 GPH) ❑ 13. CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS SUCTION/GRAVITY SYSTEM: EMERGENCY GENERATORS ONLY(Checkall that 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 all 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 GPM ❑ 15.AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)WITHOUT FLOW SHUT OFF OR ❑ 17. DAILY VISUAL CHECK RESTRICTION ❑ 16.ANNUAL INTEGRITY TEST(0.1 GPH) ❑ 17.DAILY VISUAL CHECK VIII.DISPENSER CONTAINMENT DISPENSER CONTAINMENT ® 1.FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE 0 4.DAILY VISUAL CHECK DATE INSTALLED 468 ❑ 2.CONTINUOUS DISPENSER PAN SENSOR+AUDIBLE AND VISUAL ALARMS ❑ 5.TRENCH LINER/MONITORING 1989 ❑ 3.CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR DISPENSER+AUDIBLE AND VISUAL ALARMS ❑ 6.NONE 469 IX.OWNER/OPEKILTOR 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 OFOWNER/OPERATOR(print) 471 TITLE OF OWNER/OPERATOR 472 SONIA RAY COMPLIANCE SPECIALIST Permit Number(For local use only) 473 Permit Approved(For local use only) 474 Permit Expiration Date(For load use only)475 UPCF(1/99 revised) Formerly SWRCB Form B