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qIFIED PROGRAM CONSOLIDATED FORM TANK: TA0108106 PR#: PR0231084 FAC#: FA UNDERGROUND STORAGE TANKS-TANK PAGE 2 Pagc5of`7 VI.PIPING CONSTRUCTION(check an that apply) UNDERGROUND PIPING ABOVEGROUND PIPING SYSTEM TYPE 1.PRESSURE [1 2.SUCTION ❑ 3.GRAVITY 458 E] 1.PRESSURE El 2.SUCTION 0 3.GRAVITY 459 CONSTRUCTION M I.SINGLE WALL 03.LINED TRENCH M 99.OTHER 460 0 1.SINGLE WALL ❑95.UNKNOWN 462 PU2-DOUBLE WALL E195.UNKNOWN [:1 2.DOUBLE WALL ❑99.OTHER 463 MANUFACTURER 461 MANUFACTURER ❑ 1.BARE STEEL f-I 6.FRP COMPATIBLE 100"0 METHANOL [] 1.BARE STEEL ❑ 6.FRP COMPATIBLE w/100%METHANOL ❑ 2.STAINLESS STEEL E] 7.GALVANIZED STEEL F1 2.STAINLESS STEEL ❑ 7.GALVANIZED STEEL ❑ PLASTIC COMPATIBLE W/CONTENTS El 95.UNKNOWN ❑PLASTIC COMPATIBLE W/CONTENTS 0 95.UNKNOWN 04,FIBERGLASS E] 8,FLEXIBLE(HDPE) f-1 99,OTHER ❑4.FIBERGLASS 0 8.FLEXIBLE(HOPE) ❑ 99.OTHER ❑ 5.STEEL W/COATING n 9.CATHODIC PROTECTION 464 1 F1 5.STEEL WICOATING n 9.CATHODIC PROTECTION 465 VII.PIPING LEAK DETECTION(Check all that apply)(A description of the tt,aa,it0rftw shall be submitted to the local agency.) UNDERGROUND PIPING ABOVEGROUND PIPING 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 GPM TEST WITH AUTO PUMP SHUT OFF n 1.ELECTRONIC LINE LEAK DETECTOR 3.0 GPM TEST WITH AUTO PUMP SHUT OFF FOR LEAK,SYSTEM FAILURE,AND SYSTEM DISCONNECTION+AUDIBLE AND FOR LEAK,SYSTEM FAILURE AND SYSTEM DISCONNECTION+AUDIBLE AND VISUAL ALARMS. VISUAL ALARMS. ❑2.MONTHLY 0.2 GPM TEST n 2.MONTHLY 0.2 GPM TEST El 3.ANNUAL INTEGRITY TEST(0.1 GPM) ❑3.ANNUAL INTEGRITY TEST(0.1 GPM) El 4,DAILY VISUAL CHECK CONVENTIONAL SUCTION SYSTEMS(Check ail that apply) CONVENTIONAL SUCTION SYSTEMS [-] 5.DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM ❑ 5.DAILY VISUAL MONITORING OF PUMPING SYSTEM+TRIENNIEAL PIPING INTEGRITY TEST(0.1 GPM) F1 6.TRIENNIAL INTEGRITY TEST(0.1 GPM) SAFE SUCTION SYSTEMS(NO VALUES IN BELOW GROUNDPIPING): SAFE SUCTION SYSTEMS(NO VALUES IN BELOW GROUNDPIPING): C] 7.SELF MONITORING n 7.SELF MONITORING GRAVITY FLOW GRAVITY FLOW(Check all that apply): ❑ 9.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 to.CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL ALARMS AND(Check o-) ALARMS AND(Check cac) a.AUTO PUMP SHUT OFF WHEN A LEAK OCCURS a.AUTO PUMP SHUT OFF WHEN A LEAK OCCURS E] n b.AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM Wb.AUTO PUMP SHUT OFF FOR LEAKS.SYSTEM FAILURE AND SYSTEM DISCONNECTION DISCONNECTION Ej c.NO AUTO PUMP SHUT OFF F1 t:.NO AUTO PUMP SHUT OFF 11.AUTOMATIC LINE LEAK DETECTOR(3.0 GPM TEST)WITH FLOW SHUT OFF OR n 11.AUTOMATIC LEAK DETECTOR RESTRICTION 12.ANNUAL INTEGRITY TEST(0.1 GPM) n 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 all that apply) E] 14.CONTINUOUS SUMP SENSOR WITHOQT AUTO PUMP SHUT OFF E] 14.CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF AUDIBLE AND VISUAL ALARMS AUDIBLE AND VISUAL ALARMS ❑ 15.AUTOMATIC LINE LEAK DETECTOR(3.0 GPM TEST)WITHOUT FLOW ❑ 15.AUTOMATIC LINE LEAK DETECTOR(3,0 GPM TEST)WITHOUT FLOW SHUT OFF OR RESTRICTION SHUT OFF OR RESTRICTION ❑ 16.ANNUAL INTEGRITY TEST(0.1 GPM) F1 16.ANNUAL INTEGRITY TEST(0.1 GPM) ❑ 17.DAILY VISUAL CHECK F1 17.DAILY VISUAL CHECK VIII.DISPENSERCONTAINMENTDISPENSER CONTAINMENT 1.FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE ❑4.DAILY VISUAL CHECK DATE INISTALLEDE] 5.TRENCH LINER i MONITORING 468 C] 2.CONTINUOUS DISPENSER PAN SENSOR+AUDIBLE AND VISUAL ALARMS C]3,CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR ❑6.NONE 469 DISPENSER+AUDIBLE AND VISUAL ALARMS LX.OWNERIOPERATOR SIGNATURE U I certify jhWj the information provided herein is mal accmtc to the best of ray loww-ledge, 470 '4F N ER 0 �O DATE SIG REOFOWNEROPE R e5' >A 2- il e"z TITLE OF OWNE NAMEOFOWNE PERATOR(print) 472 471 pc&it Expiration Pate(Fm beat me 0aly) T0004797 (!:r �0-v 475 Permit Nwnbu(Fmlm) Only) 473 Paffth Approved(I'm local Use WIY) 474 P - EE0003804 12/31/1993 UPCF(12/99 revised)