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Aug 13 03 12:05p Riahard Thompson 925-226-2050 p.7 UNIFIED PROGRAM CONSOLIDATED FORM SITE #2705446 PIPING UNDERGROUND STORAGE TANKS - TANTS PAGE 2 VL PIPING CONSTRUCTION (CheckaUlhat apply) Page ___ of _ IrNDFRGROI IND PIPING AROVRGROUND PIPING. SYSTEM TYPE ®1. PRESSURE ❑2. SUCTION 03. GRAVITY 458 ❑ I. PRESSURE ❑2. SUCTION ❑ 3. GRAVITY 459 ❑ 1 SINGLE WALL ❑ 3. LINED TRENCH ❑ 99. OTHER 460 F-11. SINGLE WALL [195.95. XERXES 462 UBLE WALL ❑ 95. XERXES [32, DOUBLE WALL 099. OTHER MANUFACTURER MANUFACTURER 461 MANUFACTURER 463 i0 1. BARE STEEL 0 6, FRP COMPATIBLE wr nxm METHANOL 0 1. BARE STEEL ❑6. FRP COMPATIBLE Wi I 00%METHANOL E12. STALKLESS STEEL 07. GALVANIZED STEEL E12. STAINLESS STEEL 07. GALVANIZED STEEL l MATERi MATERIACS AND i ❑ XERXES ON 3. PLASTIC COMPATIBLE WITH CONTENT'S ❑95 CORROSPROTECTION 3. PLASTIC COMPATIBLE WITH CONTENTS 08. FLEXIBLE (fIDPE) [199. OTHER [13.. BERGLASS ❑8. FLEXIBLE (HDPE) 099.OTHER ❑4. FIBERGLASS ❑9. CATHOMC PROTECTION ❑5. STEEL W/ COATING ❑9. CATHODIC PROTECTION 464 105. STEEL W/ COATING 095. XERXES 465 VIE. PIPING LEAK DETECTION (Chcokall that apply) (A desoiption ojthe tnaritaring program shall hesahmitled io the kxtrlagency) I1NDERGR6HINDPIPING AROVEGROXIN])PIPING SINGLE WALL PIPING SINGLE WALL PIPPING 467 PRESSURIZED PIPING (Cheek all that apply). PRESSURIZED PIPING (Check all that appy): ❑ I. 111-rMONIC LINE LEAK DEFECTOR 3.0 GPHTEST jj!JM AUTO PUMP SHUT OFF FOR ❑ 1. ELECTRONIC LINE LEAK DEtE•CTOR 3.0 GPH TEST VDrM AUTO PUMP SHUTOFF FOR LEAK LEA}:, SYSTEM FAILURE, AND SYSTEM DISCONNECTION +AUDIBLE AND VISUAL SYSTEM FAILURE, AND SYSTEM DISCONNYCTTON+ AUDIBLE AND VISUAL ALARMS ALARMS ❑ 2. MON'IRLY 0.2 GPH TEST El2. MONIHLY 0.2 GPH TfSr ❑ 3. ANNUAL INTEGRITY TEST (0.1 GPM ❑ ."+. ANNUAL INTEGRITY TEST(OIGPH) ❑ 4. DAILY VISUAL CHECK CONVEN71ONAL SUCTION SYSTEMS (ChcakaNthat apply): CONVENTIONAL SUCTION SYSTEMS: ❑ 5. DAILYVISUALMONnORINGOFPiPINGANDPUMPINGSYSIEM ❑ 5 DAILY VISUAL MONITORING OF PUMPING SYSTEM+IRIENNIAL PIPING INTEGRITY ® 6. TRIENNIAL INTEGRITY 73Sf (0.1 GPHI IE.ST(0.1 GPH) SAFE SUCTION SYSTEMS (NO VALVES IN BELOW GROUND PIPING): SAFE SUCTION SYSTEMS (NO VALVES IN B=- W GROUND PIPING): ❑ 7. SELF MONITORING ❑ 7. SELF MONITORING GRAVITY FLOW! GRAVITY FLOW (Cheek al(tharapply): ❑ 8. DATLYVISUALmoNTIORING ❑ 9. BIENNIAL INTEGRITY TL•SI'(0.I GPH) ❑ 9. B1EN:NiALINILGRITYIEST(O.IGPH) SECONDARILY CONTAINED PIPING SECONDARILY CONTAINED PIPING PRESSURIZED PIPING (ChakaUrltat apply): PRPSSURIZED PIPING (Cluzkaldthatappy): 10. CONTINUOUS TURBINE SUMP SENSOR WI1H AUDIBLE AND VISUAL ALARMS AND (check one) i0. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL ALARMS AND ® a AUTO Pump SHUT OFF WHEN A LEAK OCCURS (Check ona) ❑ AUTO PUMP SHITCOFF WHEN A LEAK OCCURS ❑ b. AUTO PUMP SHL? OFF FOR LEAKS, SYSTEMFAILURE AND SYSETM DISCONNECTION c. NO AUTO PUMP SHUTOFF AUTO PUMP SHUT OFF FOR LEAKS, SYSTEM FAILURE AND SYSTEM❑ ❑ 11. AUTOMATIC LEAK DETECTOR DISCO\NECTTON r ❑ c. NOAUTO PUMP SHUT OFF ❑ IZ ANNUALM EGRITYTEST(O.I GPH) I I. AUTOMATIC LINE LEAK DETECTOR (3.0 GPIs TEST) MM FLAW SHUT OFF OR SUCTIONIGRAVITY SYSTEM: RESTRICTION i❑ 17- ANNUAL INTEGRITY TEST(O. I GPH) ❑ 13. CONTIN'UpUS SUMP SENSOR + AUDIBLE AND VISUAL ALARMS . S[;CTIOViGRAVTIYSYSTEM: EMERGENCY GENERATORS ON LY (Cheticatl that apply) j ❑ 13. CONTINUOUS SUMP SENSOR + AUDIBLE AND VISUAL ALARMS ❑ 14. CONTINUOUS SUMP SEN.tiOR WITHOUT AUTO Pump SHUT OFF + AUDIBLE AND VISUAL ALARMS 11 EMERGENCY GEN ERATORS ONLY (Check all that apply) ❑ 15. AummA'ncuNELEAK DETEc'POR(3.oGPHIEs-p ❑ 14. CONTINUOUS SUMP SENSOR waHourAU1UPUMP SHUTOFF + AUDIBLE AND VISUAL ALARMS ❑ 16. ANNUAL INTEGRITY TEST (0. 1 GPH) ❑ 15. AUTOMATIC LINE LEAK DE1D-MR (3.0 GPH TEST) WI'FHOIIC FLOW SHUTOFF OR ❑ 17. DAILY VISUAL CHECK RESTRICTION ❑ 16 ANNUAL TDITEGRrryMIT (0.1GPH) ❑ 17 DAILY V15UAL CHECK VIIL DISPENSER CONTAINMENT DISPENSER CGNTATNMEN7 1. FLOAT MECHANLSM THAT SHm oFF sHEAR VALVE ❑ 4. DAILY VISUAL CHECK DATE INSTALLED 468 CONTINUOUS DISPENSER PAN SENSOR + AUDIBLE AND VISUAL ALARMS ❑ 5. TRCN04 LINER MONITORING ❑ 3. CONTINUOUS DISPENSER PAN SENSOR WTIFF AUTO SHUTOFF FOR DISPENSER+ AUDIBLE AND VISUAL ALARMS ❑ 6. NONE 469 IX. OWNERIOPERATOR SIGNATURE I cm*jbkl the infm1atian ymv ded herein is true and accrete to the best of my knowledge. SIC OFO PERATOR DATE 470 NAM RATOR (print) 471 TITLE OF OWNEWOPERAT'OR 472 J.ANETTE M. TIIOMPSON FOR CIRCLE K STORES, INC. ENVIRONMENTAL COMPLIANCE SPECIALIST Peand Number (For kcal ane arty) 473 Puma Approved (p'r r local use any) 474 Permit Expiratiwt Date (For kxaal aye cmy) 475