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-r Of FROM : JIM THORPE OIL, INC. FAX NO. : 209 368-1851 Dec. 20 2002 03:00PM P7 �Oy UNIFIED PROGRAM CONSOLIDATED FORM TA.`ri{S UNDERGROUND STORAGE TANKS -TANK PAGE 2 VI,PIPING CONSTRUcrION(chock a that ty) Page-of_ UNDERGROUND PIPING ABOVEGROUND PIPING SYSTEM TYPE Cr..PRESSURE ❑1 SUCTION ❑3.GRAVITY 458 Q 1.PRESSURE 0 2. SUCTION (]3.GRAVITY 459 CONSTRUCTION ❑1.5.1;h-CLE WALL ❑3.UNED TRLNCH 1199,OTHER 460 ❑1,SINGLE WALL ❑95•UNKNOWN 462 sI. uFACnAM MOI DOUBLE WALL ❑95.UNK.YOWv ❑2.DOUBLE WALL ❑99.OTHER MANUFACTURER 461 1 MANUFACTURER 463 ❑t.BARE STEEL 0 6.FRP COMPATIBLE w/1"i- METHANOL ❑I.BARE STEEL ❑6.FRP COMPATIBLE Wi100%NETHANOL ❑2.STAINLESS STEEL Q 7.GALVANIZED STEEL ❑Unkwwn ©2. STAINLESS STEEL [17.GALVANIZED STEEL ❑),P TIC COMPATIBLE w/CONTENTS ❑99. Other r-13, PLASTIC COMPATIBLE W/CONTENTS ❑S,FLEXIBLE(HDPE) [199.OTHER FIBERGLASS ❑S.FLEXIBLE(HDPE) ❑4. FIBERGLASS ❑9.CATHODIC PROTECTION ❑ S.STEEL W/COATING ❑9.CATHODIC PROTECTION 460 ❑S. STEEL W/COATING ❑95.UNKNOWN abs VIL PIPING LEAK DETECITON(Chock ull that 6 ly)(Adescriolion of tho"10 10rvnq program ahan fx suDmaled to dK lxal aK ) UNDERGROUND PIPING ABOVEGROUND FIPING SINGLE WALL PIPING 4" SINGLE WALL PIPING 467 PRESSURIZED PIPING(Chock all Thar appy): PRESSURIZED PIPING(Chock all that appy): - p 1,FLECTRONtc LINE LI.AK DETECTOR 3.0 GPH TEST jy=AUTO PUMP SHUT ❑1. ELECTRONIC LINE LEAK DETECTOR 3.0 GPITTEST V=ALTO PUMr OFF FOR LEAK.SYSTEM FAILURE,AND SYSTEM DISCONNECTION+ SHUT OFF FOR LEAK SYSTEM FAILURE,AND SYSTEM DISCONNECTION AUDIBLE AND VISUAL ALARMS. AUDIBLE AND VISUAL ALARMS. ❑2.MONT1tLY 0.2 GPH TEST ❑2. MONTHLY 0.2 GPH TEST ❑3,ANNUAL INTEGRITY TEST(O.IGPH) E13.ANNUAL INTEGRITY TEST(0,IGPH) C14. DAILY VISUAL CHECK CONVENTIONAL SUCTION SYSTEMS CONVENTIONAL SUCTION SYSTEMS(Check all that appy) ❑5.DAILY VISUAL MONITORING OF PUMPING SYSTEM+TRIENNIAL PIPING C1 5. DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM INTEGRITY TEST(0.1 GPH) SAFE SUCTION SYSTEMS(NO VALUES IN BELOW GROUNDPIPING): ❑6. TRIENNIAL INTEGRITY TEST(0,1 GPH) ❑7,SFLF MONITORING SAFE SUCTION SYSTEMS(NO VALVES IN BELO*GROUND PIPING): GRAVITY FLOW 07. SELF MONITORING ❑9,BIENNIAL INTEGRITY TEST(0.1 OPH) GRAVITY FLOW(Chwk all thae:.ppyy E7 S. DAILY VISUAL MONITORING ❑9. BIENNIAL INTEGRITY TEST(0.I GPH) SECONDARILY CONTAINED PIPING SECONDARILY CONTAINED PIPING PRESSURIZED PIPING(Check;dl taxr apply): PRESSURIZED PIPING(Check all that apply): 10. CON71NUOUS TURBINE SUMP SENSOR WTTH AUDIBLE AND VISUAL 10. CONTINUOUS TURBINE SUMP SENSOR=AUDIBLE,AND VISUAL ALA AND(Chaok one) ALARMS AND(CWk one) Qr.. AUTO PUMP SHUT OFF WHEN A LEAK OCCURS ❑a AUTO PUMP SHUT OFF WH>;I A LEAK OCCURS ❑b. ALTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM ❑b AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM DISCONNECTION DISCONNECTION ❑c, NO AUTO PUMP SHUT OFF Mc NO AUTO PUMP SHUT OFF MOIP.7ALTOMATIC LINE LEAK DUECTOR(3,0 GPH TEST)wZji FLOW SHUT ❑11. AUTOMATIC LEAK DETECTOR OFF OR RESTRICTION ❑ 12. ANNUAL INTEGRITY TEST(O.I GPH) ❑12. ANNUAL INTEGRITY TEST(0.1 GPH) SUC TOMORAVITY SYSTEM SUCTION/GRAVITY SYSTEM We'CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS 0 13. CONTINUOUS SUMP SrNSOR t AUDIBU AND VISUAL AIAR.NS E.NIERGENCY GENERATORS ONLY(Check,u mar appy) EMERGENCY GENERATORS ONLY(Chak au char apply) 14. CONTAtiOUS SUMP SENSOR w1 UT ALTO PUMP$HUT OFF• ❑14. CONTINUOUS SUMP SENSOR wrrmoi1T AUTO PUMP SHUT OFF" _,-AUDIBLE AND VISUAL ALARMS AUDIBLE AND VISUAL ALARMS i 3, AUTOMATIC LINE LEAK DETECTOR(3•0 GPH TEST)WIT FLOW 015. AUTOMATIC LINE LEAK DET>=CTOA(3.0 GPH TEST) SHUT OFF OR RESTRICTION ❑16.ANNUAL INTEGRITY TEST(0.1 GPH) [116.ANNUAL 1t 1TEGRYTY TEST(0,l GPH) [:117. DAILY VISUAL CHECK ❑17, DAILY VISUAL CHECK VIII.DISPENSER CONTAINiVffiNT DISPENSER CONTAINMENT 1.FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE 0f4.DAILY VISUAL CHECK DATE INSTALLED 466 ❑2.CONTINUOUS DISPENSER PAN SENSOR+AUDIBLE AND VISUAL ALARMS ❑S.TRENCH LINER/MONITORING ❑3.CONTINUOUS DISPENSER PAN SENSOR WITK AUTO SHUT OFF FOR ❑6 NONE 469 DISPENSER+AUDIBLE AND VISUAL ALARMS IX.OWNERIOPERATOR SIGNATURE I epvty mar toe ado tion Ixov aerejrt�x leu �ecurate� y � IGNATU ERATO I ATE 4;0 N O o t) a71 T OF pWNL• PE t0 471- pmsnit Number(F61 Ionr use only) F 473 4F Pamir Approved(For 1m:u1 uee only) 474 Pe mk expiration tate(For hod u e only) 375 LIPCF(12/99 revised) Formerly SWRCB Form B