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05/20/2004 09:25 7074464OR6 CAL INC PAGE 06 <br /> TINTIpTF,n pjznr.RAi,,F rnNqm,mATFD RVI <br /> TANKS <br /> UNDERGROUND STOR&GE TANKS-TANK PAGE 2 Pmm <br /> I'age 2 Of 2 <br /> UNDERGROUND PEPING ABOVEGROUNDPIPLNG <br /> SYSTEM TYPE [3 1.PRESSURE og 2.SUCTION 0 3,5RAVITY asa. [3 1,PRESSURE 9 2.SUC70N L3 3,GRAVITY 459. <br /> CONSTRUCTION/ []1.SINGLE WALL. El 3.LINED TNEN014 0 99 OTHER 460. 0 1.SINGLE WALL 0 OS.UINKNOWN <br /> MANUFACTURER IM 2,DOUBLE WALL ED 95.UNKNOWN 0 2,DOTJaTR WALL Ll 99,OTHER <br /> MANUFACTURER UnknOWn 40- NfANUFACTURPR Unknowii 463. <br /> [11.BARE STaL El 6.Ilk?COMPATIBLE Wtl 00%MIFTHANOL ❑1,BARE STEEL [3 6.FRP COMPATIBLE W11001/4 MMIANOL <br /> 0 2.STAINLESS STEEL 0 7.GALVANIZED STEEL [I 2.$TA1NLr-SS STEEL 0 7.GALVANIZED STEEL <br /> 3.PLASTIC COMPATIBLE WITH CONTENTS C1 95.UNKNOWN Q,4.PLASTIC COMPATIBLE W/CONTENTS El E.FLEXIBLE(IIDPE) 0 99.OTHER <br /> 4.FIBERGLASS Q s.FLEXIBLE(RD1,F) LI 99 OTHER 194.FIBERGLASS El 9.CATHODIC PPO'TFCTMN <br /> E35,STEEL WCOATING tj 9.CATHODIC PROTECTION 464- Ef 5,STEEL W/COAT= 0 95.UNKNOWN 465. <br /> tbed WAIL laeo Aphty.). <br /> UNDERGROUND PIPING ABOVEGROUND PIPING <br /> SINGLE WALL PIPING 46d. SINGLE WALL P(PAN(.- 4167. <br /> PRESSUR12ND nnNG(Cbock all that apply); PRESSURIZED PIPING(C.beck PJL that apply;): <br /> ❑1. ELECfRONIC LINE LEAF,DETECTOR 3.0 GPH TEST B117H AUTO PIW ❑1. ELECTRONIC LINIS LEAK DETECTOR 3,0 GPII TEST WITH AUTO PUMP <br /> S14TJT-,QFF FOR LBAf-SYSTEM FAILURE,AND SYSTEM DISCONNEC11ON SENT Orr POP LEAK,SYSTEM FAILURE,AND SYSTEM[DISCONNECTION <br /> +AUDIBLE AND VISUAL ALARMS. +ACiDTBT.P AND VISUAL ALARMS. <br /> ❑2. MONTHLY 0.2 GPI]TOT ❑z. MONTHLY 0.2 GPH TEST <br /> [33, ANNUALINTEGRITY TEST NAGPI0 [33. ANNUAL INTEGRITY TEST(0.1 GPI-I) <br /> [34. DAILY VISUAL('MFCK <br /> CONVENTIONAL,SUCTION SYSTEMS CONVENTIONAL SUCTION SYSTEMS(Check all that apply) <br /> 05, DAILY VISUAL MONITORING OF PUMPING SYSTEM+TRIENNIAL Plk LNG [3j. DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM <br /> INTEGRITY TEST(0.1 OPH) <br /> SAFE SUCTION SYSTEMS(No VALVES IN BELOW GROUND PIPING): Q6- TRIENNIAL INTEGRITY TPST(0.1GPII) <br /> 09 7, SELF MONITORING SAFE SUCTION SVISTIEroft(NO VALVES IN BELOW GROUND PIPING): <br /> OPUAVITYFLOW P97. SELPMON17IORING <br /> [39. 9112-NNIALL17TEGRITY TEST(0,1 GPII) GRAVITY FLOW(Chock all that apply): <br /> L38. DAILY Vf.5UAT,MONITORING <br /> [19. WFIsNL&L INTEORITY TEST(0.1 GPH) <br /> SECONDA9MY CONTAMD PIPTNC SECONDARILY CONTAINED PTINING <br /> MESSUR3ZED PIPING(Chock all That 4VIY)! PRESSURIZED PIPANG(Check all dut apply): <br /> 10. CONTINUOUS TURBINE SUMP SENSOR WITH AUD313T.F. ANT) VTS'jAr, 10. CONTINUOUS TURBINE SUMP SENSOR AIM AUDIBLE AXD VISUAL <br /> ALAT.W AA\7)(CboclL one) ALARMS AND(Cb4ck ope) <br /> 0 a,AUTO PUMP SHUT OFF WHEN A LEAK OCCURS ❑.AUTO PUMP SHUT OFF WHEN A LEAK OCCURS <br /> D b.AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND Sys IBM b,AUTO PUMP 31WT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM <br /> DISCONNECTION DISCONN13CTION <br /> EIC, NO AUTO PUMP SHUT OFF Oc. 140 ALTO PUMP SHUT OFF <br /> E3 11. AUTOMATIC LINE LEAK DETECTOR(3.0 GPII TEST)M=I FLOW SHUT 0 11,AUTOMATIC LEAK DETECTOR <br /> OFF OR RESTRICTION <br /> C]12. ANNUAL YDXr);CtkITV T15$T(0.1 GPH) [112.ANNUAL 1NTEGRITY TEST(0,1 GPH) <br /> SUCTIQN/<;RAVffY SYSTEM SUCTION/GRAVM SVSTFM <br /> 013. CONTINUOUS 9UX. F SENSOR+AUDIBLE AND VISUAL ALARMS IM 13.CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS <br /> ZMEKGENcl=NrXATOXS ONLY(Check At that apply) EMERGENCY GENZRATORS OXLY('Chock all that apply) <br /> ❑14. CONTINUOUS SUNIP SENSOR WITHOUT AUTO PUMP SHUT OFF 0 14.CONTINUOUS SUMP SENSOR"Tgarr AUTOPUMP SI1UT,OFF <br /> AUDIBLE AND VlSt?AL ALARMS AUDIBLE AND VISUAL ALARMS <br /> [115, AUTOMATIC LINE LEAK DETECTOR (3,0 GPH TEST) W171 OUT FLOW El IS.AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST) <br /> SHUT OFF OR RESTRICTION <br /> Q 16. ANNUAL INTEGRITY TEST(0.1 GPH) 0 16.ANNUAL INTEGRITY TEST(0.1 GPH) <br /> 17. DAILY VISUAL CRECK [137.DAILY VISUAL CHECK <br /> VIII.DISPENSER CONTAINMENT <br /> DISMNSER CONTAD&ffiNT 4a. Ell. FLOAT MECHANISM THAT SEUIS OFF SHEAR VALVE [14, DAILY VISUAL CHECK 469, <br /> DATE INSTALLED [12. CONTINUOUS DISPENSER PAN SENSOR+AUDIBLE AND VISUAL ALARMS [15. TRENCii/LiNERmONITORING <br /> 4/2004 03. CONTINUOUS DISPENSER P kN SENSOR MM AUTO SHUT OFF FOR C1 6. NONE <br /> DXSPVN';PR+AU011906 AND A rARV$o <br /> 1X.OW.N9R/Q, #ZRATQR SIGNATURE. <br /> I certify that the information provided bordi;,is jqio and accurate to the best oj my knowlodgc. <br /> SIGNATURE OF OWNER/OPERATOR DATE: l 470. <br /> NAME OF OWNER/OPERATOR(print) IT472. <br /> 60ILE OF OWNER/OPERATOR. i'tT.T." Awe'w -C-Avvc <br /> I <br /> Pomit Number(Agency use only) 47?. Permit Approved By.Ag*wyuw9n1:y) 474, Pormil Expiration Date(Agevoy use only) 477 <br /> UFCF hwfwire-b(1/99)-3/4 http.'/jwwwmnjdoCs.ovx Rev.02/16100 <br />