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NIFIED PROGRAM CONSOLIDATED FORM TANKS UNDERGROUND T GE TANKS -TANK PAGE 2 VI.PIPING CONSTRUCTION(Check a9 that apply) UNDERGROUND PIPING ' ABOVEGROUND PIPING SYSTEM TYPE 1 PRESSURE ❑ 2. SUCTION ❑ 3. GRAVITY ❑ 1. PRESSURE ❑ 2. SUCTION ❑ 3. GRAVITY CONSTRUCTION/ ❑ 1. SINGLE WALL ❑ 3. LINED TRENCH ❑99. OTHER ❑ 1. SINGLE WALL ❑95. UNKNOWN MANUFACTURERAMN 2. DOUBLE WALL ❑95. UNKN,,ppyy,,WN ❑ 2. DOUBLE WALL ❑99. OTHER MANUFACTURER - S il� MANUFACTURER - - ❑ 1.BARE STEEL X. FRP COMPATIBLE W/100%METHANOL ❑ 1. BARE STEEL ❑ 6. FRP COMPATIBLE W/100%METHANOL MATERIALS AND ❑ 2, STAINLESS STEEL ❑ 7. GALVANIZED STEEL ❑ 2. STAINLESS STEEL CORROSION ❑ 7. GALVANIZED STEEL PROTECTION ❑ 3. PLASTIC COMPATIBLE WITH CONTENTS ❑95. UNKNOWN ❑ 3. PLASTIC COMPATIBLE WITH CONTENTS ❑ 8. FLEXIBLE(HDPE) ❑99. OTHER ❑ 4. FIBERGLASS ❑ S. FLEXIBLE(HDPE) ❑99. OTHER ❑ 4. FIBERGLASS ❑ 9. CATHODIC PROTECTION ❑ S. STEEL W/COATING ❑ 9. CATHODIC PROTECTION ❑ 5. STEEL W/COATING ❑95. UNKNOWN VII.PIPING LEAK DETECTION(Check a8 that appW UNDERGROUND PIPING ABOVEGROUND PIPING SINGL�IYALL ING PRESPING CheckEat I SINGLE WALL PtPtNG ( apply): PRESSURIZED PIPING(Check alf that apply): ❑ 1. ELECTRONIC LINE LEAK DETECTOR 3.0 GPM TEST WITH AUTO PUMP SHUT OFF FOR ❑ 1. ELECTRONIC LINE LEAK DETECTOR 3.0 GPM 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 0.2 GPM TEST ❑ 2. MONTHLY 0.2 GPM TEST ❑ 3. ANNUAL INTEGRITY TEST(0.1 GPM) ❑ 3.ANNUAL INTEGRITY TEST(0.1 GPM) ❑ 4. DAILY VISUAL CHECK CONVENTIONAL SUCTION SYSTEMS: CONVENTIONAL SUCTION SYSTEMS(Check all that apply): ❑ 5. DAILY VISUAL MONITORING OF PUMPING SYSTEM.TRIENNIAL PIPING INTEGRITY ❑ S. DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM TEST(0.1 GPM) ❑ 6. TRIENNIAL INTEGRITY TEST(0.1 GPM) 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 alf that apply): 119. BIENNIAL INTEGRITY TEST(0.1 GPM) ❑ 8. DAILY VISUAL MONITORING ❑ 9. BIENNIAL INTEGRITY TEST(0.1 GPM) SECONDARILY CONTAINED PIPING SECONDARILY CONTAINED PIPING PRESSURIZED PIPING(Check all that apply): PRESSURIZED PIPING(Check all that apply): 10. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL ALARMS AND (Check one) 10.CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL ALARMS AND(check one) ❑ a. AUTO PUMP SHUT OFF WHEN A LEAK OCCURS ❑ a. AUTO PUMP SHUT OFF WHEN A LEAK OCCURS Ab AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM DISCONNECTION 13b. AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM DISCONNECTION ❑ c. NO AUTO PUMP SHUT OFF ❑ C. NO AUTO PUMP SHUT OFF 11, AUTOMATIC LINE LEAK DETECTOR(3.0 GPM TEST)WITH FLOW SHUT OFF OR RESTRICTION 1111.AUTOMATIC LEAK DETECTOR ❑ 12. ANNUAL INTEGRITY TEST(0.1 GPM) ❑ 12.ANNUAL INTEGRITY TEST(0.1 GPM) SUCTION/GRAVITY SYSTEM: SUCTION/GRAVITY SYSTEM: ❑ 13. CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS ❑ 13.CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS EMERGENCY GENERATORS ONLY(Check all that apply) EMERGENCY GENERATORS ONLY(Check as that apply) ❑ 14. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF+AUDIBLE AND ❑ 14.CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF+AUDIBLE AND VISUAL VISUAL ALARMS ALARMS ❑ 15. AUTOMATIC LINE LEAK DETECTOR(3.0 GPM TEST)WITHOUT FLOW SHUT OFF OR ❑ 15.AUTOMATIC UNE LEAK DETECTOR(3.o GPM TEST) RESTRICTION ❑ 16. ANNUAL INTEGRITY TEST(0.1 GPM) ❑ 16.ANNUAL INTEGRITY TEST(0.1 GPM) ❑ 17. DAILY VISUAL CHECK ❑ 17. DAILY VISUAL CHECK VUL DISPENSER CONTAINMENT DISPENSER CONTAINMENT 1. FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE ❑ 4. DAILY VISUAL CHECK DATE I STALLED ❑ 2. CONTINUOUS DISPENSER PAN SENSOR+AUDIBLE AND VISUAL ALARMS _ ❑ 5. TRENCH LINER/MONITORING III ❑ 3. CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR DISPENSER+AUDIBLE AND VISUAL ALARMS ❑ 8. NONE IX.OWNER/OPERATOR SIGNATURE 1 certify that the information provided herein is true and accurate t0 the hest of my knowledge. SIGNATUR/ OR DATE 0 OWNE NAME OF O ,ER/OPERAT (p t) TITLE OF ER/OPETOR Permit Number(For local use only) Permit Approved(For local use only) Permit Expiration Date(Forlocal use only) CUPAFORM(4/99) Formerly SWRCB Form B