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L o •a.' ED PROGRAM CONSOLIDATED F(* SITE#2705447/05447 PIPING UNDERGROUND STORAGE TANKS - TANK PAGE 2 VI.PIPING CONSTRL CTION(Check all that apply) Page of UNDERGRQUND PIPING ABOVEGROUND PIPING SYSTEM TYPE L5CPPESSURE ❑2.SUCTION ❑3.GRAVITY 458 ❑1.PRESSURE ❑2.SUCTION ❑3.GRAVITY 459 CONSTRUCTION/ [11.SINGLE WALL El 3.LINED TRENCH [199.OTHER 460 El 1.SINGLE WALL [:195.XERXES 462 MANUFACTURER 2.DOUBLE WALL ❑95.XERXES [12.DOUBLE WALL [:199.OTHER MANUFACTURER 461 MANUFACTURER 463 ❑1.BARE STEEL ❑6.FRP COMPATIBLE Wt too-/.METHANOL [:11.BARE STEEL ❑6.FRP COMPATIBLE W/100%METHANOL MATERIALS AND ❑2.STAINLESS STEEL ❑7.GALVANIZED STEEL ❑2.STAINLESS STEEL ❑7.GALVANIZED STEEL CORROSION ❑3.PLASTIC COMPATIBLE WITH CONTENTS ❑95.XERXES 03.PLASTIC COMPATIBLE WITH CONTENTS ❑8.FLEXIBLE(HDPE) 099.OTHER PROTECTION ERVIFIBERGLASS ❑8.FLEXIBLE(HDPE) E:199.OTHER ❑4. FIBERGLASS ❑9.CATHODIC PROTECTION E.STEEL W/COATING ❑9.CATHODIC PROTECTION 464 ❑5. STEEL W/COATING ❑95. XERXES 465 VII.PIPING LEAK DETECTION(Check all that apply)(A description of the monitoring program shall be submitter/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 GPH TEST WITH AUTO PUMP SHUT OFF FOR ❑ 1. ELECTRONIC LINE LEAK DETECTOR 3.0 GPH 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 2. MONTHLY 0.2 GPH TEST . MONTHLY 0.2 GPH TEST ❑ 3 ❑ 3. ANNUAL INTEGRITY TEST(0.1 GPH) . ANNUAL INTEGRITY TEST(0.1 GPH) ❑ 4. DAILY VISUAL CHECK CONVENTIONAL SUCTION SYSTEMS: CONVENTIONAL SUCTION SYSTEMS(Check all that apply):❑ 5 DAILY VISUAL MONITORING OF PUMPING SYSTEM+TRIENNIAL PIPING INTEGRITY El 5. DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM TEST(0.1 GPH) ❑ 6. TRIENNIAL INTEGRITY TEST(0.1 GPH) 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 GPH) ❑ 8. DAILY VISUAL MONITORING ❑ 9. BIENNIAL INTEGRITY TEST(O.1 GPH) 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 10, CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL ALARMS AND(check one) (Check 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 DISCONNECTION -19�b AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM F-1c. NO AUTO PUMP SHUT OFF DISCONNECTION ❑ 11. AUTOMATIC LEAK DETECTOR ❑ c. NO AUTO PUMP SHUT OFF ❑ 12. ANNUAL INTEGRITY TEST(0.1 GPH) 11. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)WITH FLOW SHUT OFF OR RESTRICTION SUCTION/GRAVITY SYSTEM: ❑ 12. ANNUAL INTEGRITY TEST(0.1 GPH) ❑ 13. CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS SUCTION/GRAVITY SYSTEM: EMERGENCY GENERATORS ONLY(Check all that apply) ❑ 13. CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS ❑ 14. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF+AUDIBLE AND VISUAL ALARMS EMERGENCY GENERATORS ONLY(Check all that apply) ❑ 15. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST) ❑ 14. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF+AUDIBLE AND VISUAL ALARMS 16. ANNUAL INTEGRITY TEST(0.1 GPH) ❑ 15. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)WITHOUT FLOW SHUT OFF OR ❑ 17. DAILY VISUAL CHECK RESTRICTION ❑ 16. ANNUAL INTEGRITY TEST(0.1 GPH) ❑ 17_ DAILY VISUAL CHECK VIII.DISPENSER CONTAINMENT DISPENSER CONTAINMENT 1.FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE ❑ 4.DAILY VISUAL CHECK DATE INSTO 468 .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 ❑ 6.NONE 469 IX.OWNER/OPERATOR SIGNATURE I certify that the information provided herein is true and accurate to the best of my knowledge. SIG RE OF OWER/OPERATOR DATE 470 NAME'6F OWNER/OPERA R(print) 471 TITLE OF OWNER/OPERATOR 472 JANETTE M.THOMPSON FOR CIRCLE K STORES,INC. COMPLIANCE SPECIALIST Permit Number(For local use only) 473 Permit Approved(For local use only) 474 1 Permit Expiration Date(For local use only)475