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3 <br /> } IWIED PROGRAM CONSOLIDATED FO is <br /> TANK <br /> UNDERGROUND STORAGE TANKS -TANK PAGE 2 <br /> VI.PIPING CONSTRUCTION Check all that apply) Page 2 of 10 <br /> UNDERGROUND PIPING ABOVEGROUND PIPING <br /> SYSTEM TYPE ®1.PRESSURE ❑2.SUCTION ❑3.GRAVITY 458 ❑L PRESSURE ❑2. SUCTION ❑3.GRAVITY 459 <br /> CONSTRUCTION [11.SINGLE WALL ❑3.LINED TRENCH ❑99.OTHER 460 ❑1.SINGLE WALL ❑95.UNKNOWN 462 <br /> MANUFACTURER ®2.DOUBLE WALL ❑95.UNKNOWN ❑2.DOUBLE WALL ❑99.OTHER <br /> MANUFACTURER AO Smith 461 MANUFACTURER 463 <br /> ❑1.BARE STEEL ❑6.FRP COMPATIBLE w/I00% METHANOL ❑1.BARE STEEL ❑6.FRP COMPATIBLE W/100 METHANOL <br /> ❑2.STAINLESS STEEL [17.GALVANIZED STEEL ❑Unknown ❑2. STAINLESS STEEL ❑7.GALVANIZED STEEL <br /> ❑3.PLASTIC COMPATIBLE W/CONTENTS ❑99. Other ❑3. PLASTIC COMPATIBLE W/CONTENTS ❑8.FLEXIBLE(HDPE) [199. OTHER <br /> ®4.FIBERGLASS [18.FLEXIBLE(HDPE) ❑4. FIBERGLASS [19.CATHODIC PROTECTION <br /> [15.STEEL W/COATING ❑9.CATHODIC PROTECTION 464 [15. STEEL W/COATING [195.UNKNOWN 465 <br /> VII.PIPING LEAK DETECTION(Check all that apply)(A descri tion of the monitoring program shall be submitted to the local agency.) <br /> UNDERGROUND PIPING ABOVEGROUND PIPING <br /> SINGLE WALL PIPING 466 SINGLE WALL PIPING 467 <br /> PRESSURIZED PIPING(Check all that apply): PRESSURIZED PIPING(Check all that apply): <br /> ❑1.ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP SHUT [11. ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP <br /> OFF FOR LEAK,SYSTEM FAILURE,AND SYSTEM DISCONNECTION+ SHUT OFF FOR LEAK,SYSTEM FAILURE,AND SYSTEM DISCONNECTION+ <br /> AUDIBLE AND VISUAL ALARMS. AUDIBLE AND VISUAL ALARMS. <br /> ❑2.MONTHLY 0.2 GPH TEST [12. MONTHLY 0.2 GPH TEST <br /> ❑3.ANNUAL INTEGRITY TEST(0.1 GPH) [13.ANNUAL INTEGRITY TEST(0.1GPM <br /> ❑4. DAILY VISUAL CHECK <br /> CONVENTIONAL SUCTION SYSTEMS CONVENTIONAL SUCTION SYSTEMS(Check all that apply) <br /> ❑5.DAILY VISUAL MONITORING OF PUMPING SYSTEM+TRIENNIAL PIPING [15. DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM <br /> INTEGRITY TEST(0.1 GPH) <br /> SAFE SUCTION SYSTEMS(NO VALUES IN BELOW GROUND PIPING): ❑6. TRIENNIAL INTEGRITY TEST(0.1 GPH) <br /> [17.SELF MONITORING SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): <br /> GRAVITY FLOW [17. SELF MONITORING <br /> ❑9.BIENNIAL INTEGRITY TEST(0.1 GPH) GRAVITY FLOW(Check all that apply): <br /> [18. DAILY VISUAL MONITORING <br /> [19. BIENNIAL INTEGRITY TEST(0.1 GPH) <br /> SECONDARILY CONTAINED PIPING SECONDARILY CONTAINED PIPING <br /> PRESSURIZED PIPING(Check all that apply): PRESSURIZED PIPING(Check all that apply): <br /> 10. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL 10. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL <br /> ALARMS AND(Check one) ALARMS AND(Check one) <br /> ❑a. AUTO PUMP SHUT OFF WHEN A LEAK OCCURS ❑a AUTO PUMP SHUT OFF WHEN A LEAK OCCURS <br /> AUTO PUMP SHUT,OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM ❑b AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM <br /> DISCONNECTION WhC 0(C*C* DISCONNECTION <br /> . NO AUTO PUMP SHUT OFF ❑c NO AUTO PUMP SHUT OFF <br /> ®11. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)WITH FLOW SHUT ❑11. AUTOMATIC LEAK DETECTOR <br /> OFF OR RESTRICTION <br /> ®12. ANNUAL INTEGRITY TEST(0.1 GPH) ❑12. ANNUAL INTEGRITY TEST(0.1 GPH) <br /> SUCTION/GRAVITY SYSTEM SUCTION/GRAVITY SYSTEM <br /> [113. CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS [113. CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS <br /> EMERGENCY GENERATORS ONLY(Check all that apply) EMERGENCY GENERATORS ONLY(Check all that apply) <br /> ❑14. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF* [114. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF <br /> AUDIBLE AND VISUAL ALARMS AUDIBLE AND VISUAL ALARMS <br /> [115. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)WITHOUT FLOW [115. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST) <br /> SHUT OFF OR RESTRICTION <br /> ❑16.ANNUAL INTEGRITY TEST(0.1 GPH) [116.ANNUAL INTEGRITY TEST(0.1 GPH) <br /> ❑17. DAILY VISUAL CHECK ❑17. DAILY VISUAL CHECK <br /> VIII.DISPENSER CONTAINMENT <br /> DISPENSER CONTAINMENT ❑1.FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE ❑4.DAILY VISUAL CHECK <br /> DATE INSTALLED 468 ®2.CONTINUOUS DISPENSER PAN SENSOR+AUDIBLE AND VISUAL ALARMS ❑5.TRENCH LINER/MONITORING <br /> 3.CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR ❑6.NONE 469 <br /> 1996 DISPENSER+AUDIBLE AND VISUAL ALARMS <br /> IX.OWNER/OPERATOR SIGNATURE <br /> I certify that the information provided herein is true and accurate to the best of my knowledge. <br /> SIGNATURE OF OWNER/OPERATOR DATE 470 <br /> 3/6/00 <br /> NAME OF OWNER/OPERATOR(print) TITLE OF OWNER/OPERATOR 472 <br /> Chevron Products Company/DR LERI Retail ESH Specialist <br /> Permit Number(For local use only) 473 Permit Approved(For local use only) Permit Expiration Date(For local use only) 475 <br /> UPCF(1/99 revised) 174 Formerly SWRCB Form B <br />