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IFIED PROGRAM CONSOLIDATED 149M SITE#255417/5417 TANKS UNDERGROUND STORAGE TANKS - TANK PAGE LO-3 VI.PIPING CONSTRUCTION(Checkallthatapply) Page _ of UNDER ROUND PIPING ABOVEG&QUND PIPIN SYSTEM TYPE ®1.PRESSURE 2.SUCTION 3.GRAVITY 458 1.PRESSURE Q2.SUCTION 3.GRAVITY 459 ®1.SINGLE WALL ❑3.LINED TRENCH ❑99.OTHER 460 [j1.SINGLE WALL [195.XERXES 462 CONSTRUCTION/ MANUFACTURER ®2.DOUBLE WALL [195.XERXES [12.DOUBLE WALL [199.OTHER MANUFACTURER 461 MANUFACTURER 463 1.BARE STEEL 06.FRP COMPATIBLE W 1006 METHANOL 0 1.BARE STEEL E36.FRP COMPATIBLE W/100%METHANOL MATERIALS AND 02.STAINLESS STEEL ❑7.GALVANIZED STEEL 02.STAINLESS STEEL 07.GALVANIZED STEEL CORROSION ❑3.PLASTIC COMPATIBLE WITH CONTENTS ❑95.XERXES ❑3.PLASTIC COMPATIBLE WITH CONTENTS ❑8.FLEXIBLE(HDPE) ❑99.OTHER PROTECTION 04.FIBERGLASS ❑8.FLEXIBLE(HDPE) ❑99.OTHER 04. FIBERGLASS 09.CATHODIC PROTECTION 5.STEEL W/COATING 9.CATHODIC PROTECTION 464 1:15. STEEL W/COATING 095. XERXES 465 VIL PIPING LEAK DETEC`PION(Check all that apply)(A description of the nionitoringprogram shall be submitted to the local agency.) UNDERGROUND 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 OPH 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 02 GPH TEST ❑ 2.MONTHLY 0.2 GPH TEST [13. ANNUAL INTEGRITY TEST(0.1 GPH) ❑ 3.ANNUAL INTEGRITY TEST(0.1 GPH) ❑ 4. DAILY VISUAL CHECK CONVENTIONAL SUCTION SYSTEMS: CONVENTIONAL SUCTION SYSTEMS(Check al/that apply): ❑ 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(o.I 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): 10.CONTINUOUS TURBINE SUMP SENSOR AUDIBLE AND VISUAL ALARMS AND 10.CONTINUOUS TURBINE SUMP SENSOR AUDIBLE AND VISUAL ALARM 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 1NTEGRrrY TEST(0.1 GPM ® I1.AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)WITH FLOW SHUT OFF OR RESTRICTION SUCTION/GRAVITY SYSTEM: ® 12.ANNUAL INTEGRITY TEST(0.1 OPH) ❑ 13. CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS SUCTION/GRAVITY SYSTEM: EMERGENCY GENERATORS ONLY(Checka/l 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(Checkau 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)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.HAAT 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 2001 ❑ 3.CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR DISPENSER+AUDIBLE AND VISUAL ALARMS ❑ 6.NONE 469 IX OWNER/OPER#TOR SIGNATURE I certify that the information provided herein is true and accurate to the beat of my kmowledge. 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 on(y) 473 Permit Approved(For local use only) 474 Permit Expiration Dau(For local use only)475 UPCF(1/99 revised) Formerly SWRCB Form B