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NIFIED PROGRAM CONSOLIDATED FOR r TANKS UNDERGROUND STORAGE TANKS-TANK PAGE 2 we of w PIPub tTRtroN � » 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 111. SINGLE WALL ❑95. UNKNOWN MANUFACTURER L7 2. DOUBLE WALL /A\ Jn�'�QS. U OWN ,i ❑ 2. DOUBLE WALL ❑99. OTHER - MANUFACTURER ET (TE'T MANUFACTURER ❑ 1.BARE STEEL ❑ 8. FRP COMPATIBLE W/100%METHANOL ❑ 1. BARE STEEL ❑ 8. FRP COMPATIBLE Al 100%METHANOL MATERIALS AND ❑ 2. STAINLESS STEEL ❑ 7. GALVANIZED STEEL ❑ 2. STAINLESS STEEL ❑ 7. GALVANIZED STEEL CORROSION PROTECTION ❑ 3. STIC COMPATIBLE WITH CONTENTS 1195. UNKNOWN ❑ 3. PLASTIC COMPATIBLE WITH CONTENTS ❑ 8. FLEXIBLE(HDPE) - ❑99. OTHER 4. FIBERGLASS 13B. FLEXIBLE(HDPE) 1199. OTHER ❑ 4. FIBERGLASS ❑ 9. CATHODICPROTF,CtIONy F 1 e ♦r.,, ❑ 5. STEEL W/COATING ❑ 9. CATHODIC PROTECTION ❑ S. STEEL W/COATING ❑95. UNKNOWN WM PIPINC4 LEAKtK1?i(CAuk a1► eppyjVN UNDERGROUND PIPING ABOVEGROUND PIPING'..,; SINGLE WALL PIPING SINGLE WALL PIPING - PRESSURIZED PIPING(Check all that apply): PRESSURIZED PIPING(Check ap 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 SHUTOFF 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 ❑ 5. DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM TEST(0.1 GPM) ❑ 8. 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 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&#that apply): 10. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL ALARMS AND P10.CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL ALARMS AND(cheek one) P(Che -one) a AUTO PUMP SHUT OFF WHEN A LEAK OCCURS ❑ a. AUTO PUMP SHUT OFF WHEN A LEAK OCCURS ❑ b. AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM ❑ b. AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM DISCONNECTION DISCONNECTION ,�'- 13c. NO AUTO PUMP SHUT OFF El C. NO AUTO PUMP SHUT OFF � 11. AUTOMATIC LINE LEAK DETECTOR(3.0 GPM TEST)WITH FLOW SHUT OFF OR ❑ 11,AUTOMATIC LEAK DETECTOR RESTRICTION ❑ 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 al that apply) EMERGENCY GENERATORS ONLY(Check all 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 LINE LEAK DETECTOR(3.0 GPM TEST) RESTRICTION ❑ 18. ANNUAL INTEGRITY TEST(0.1 GPM) ❑ 18. ANNUAL INTEGRITY TEST(0.1 GPM) ❑ 17. DAILY VISUAL CHECK ❑ 17. DAILY VISUAL CHECK V�:�18I�I�,Eaxt#�ffEAIf�IIIE�T'.. DISPENSER CONTAINMEN . FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE ❑ 4. DAILY VISUAL CHECK DATE INSTALLED 2. CONTINUOUS DISPENSER PAN SENSOR+AUDIBLE AND VISUAL ALARMS ❑ 5. TRENCH LINER/MONITORING ❑ 3. CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR DISPENSER+AUDIBLE AND VISUAL ALARMS ❑ 8. NONE JX.OWNER/OPERATOR SIGNATURE I certify that the information provided herein is true and accurate to Bre best of my knowledge. UR OWNER/OP BATOR , DATE p NAME OF OWNER/O ATOR(nM) ^ v TITLE OtIDWNERIO ERATOR r n Permit Number(For local use only) V\ Permit Approved(For We/use onW r�`Permit Expiref on Deb(Forlocal use only) ti i CUPAFORM(4/99) • • Formerly SWRCB Form 8