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R� A A FROM JIM THORPE OIL, INC. • FAX NO. : 209 368-1851 . Dec. 20 2002 002:59PM P4 UNIFIED PROGRAM(:ONSOLIDATED FORM TANKS UNDERGROUND STORAGE TANKS TANK PAGE 2 VI.PIPING CONSTRUCTION((neck all that 1) Pngc_.or- UNDERGROUND PIPfNG I ABOVEGROUND PIPING __ ✓� _ RYSTEM'I'YPE PRESSURE ❑2.SUCTION [13,GRAVITY 458 (:11.PRESSURE Q 2. SUCTION ❑3.GRAVITY 459 CONSTRUCTION ❑L. LE WALL ❑3.L1NFD TRENCH [199,OTHER 460 ❑1.SINGLE WALL ❑95.UNKNOWN 462 M,WUFACTURER DOUBLE WALL []95.UNKNOWN ❑2.DOUT1I.E WALL ❑99.OTHER MANUFACTURER 461 MANUFACTURER 463 Q 1.BARE STEEL ©6.FRP COMPATIBLE w/100°/+ mETR NOL ❑1.BARE STEEL E3 6.FRP COMPATIBLE WI100%MGTI ANOL ❑2.STAINLESS STEEL [17,GALVANIZED STEEL ❑Unknown ❑2. STAINLESS STEEL Q 7,GALVANIZED STEEL ❑ C COMPATIBLE W/CONTENTS ❑99. OtW CI 3.PLASTIC COMPATIBLE W/CONTENTS [Is.FuxmLE(ITDPE) 1:199. OTHER FIBERGLASS ❑8.FLEXIBLE(HDPE) Q 4.FIBERGLASS ❑9.CATHODIC PROTECTION ❑5.STEEL W/COATING ❑9.CATHODIC PROTECTION 464 ❑5. STEEL W/COATING ❑95.UNKNOWN 465 VII.PIPING LEAK DETECTION{(:heck all that apply)(A . iun of the imnitoring prograrn shall be subm'atod to the local agency.) UNDERGROUND PIPING ASOVEGROITND PIPING SINGLE WALL PIPING 466 SINGLE WALL PIPING 467 PRESSURIZED PIPING((leek all that apply): PRESSURIZED PIPING(Check an that apply): ❑1,ELF.CTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP SHUT ❑1, ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP OFF'FOP.LEAK,SYSTEM FAILURE.AND SYSTEM DISCONNECTION+ SHUT OFF FOR LEAK.SYSTEM FAILURE.AND SYSTEM DISCONNECTION+ AUDIBLE AND VISUAL ALARMS. AUDIBLE AND VISUAL ALARMS. ❑2.MONTHLY 0.2 OPH TEST [12, MONTHLY 0.2 OPH TEST ©}.ANNUAL INTEGRITY TEST(0,IGPI1) [13.ANNUAL.TNTEGRITY TEST(O.IGPH) ❑4. DAILY VISUAL CHECK CONVENTIONAL SUCTION SYSTEMS CONVENTIONAL SUCTION SYSTEMS(Check all that apply) 0 5.DAILY VISUAL MONITORING OF PUMPING SYSTEM+TRIENNIAL PIPING ❑S. DAILY VISUAL MONITORING,OF PIPING AND PUMPING SYSTEM INTEGRITY TEST(0.l GPH) SAFE SUCTION SYSTFMS(NO VALUES IN BELOW GROUNDPIPING): ❑6. TRIENNIAL INTEGRITY TEST(0.1 GPH) Q 7.SELF MONITORING SAFE SUCTION SYSTEMS(NO VALVES IN BELO*GROUND PIPING): GRAVITY FLOW 0 7. SELF MONITORING ❑9.BIENNIAE.INTEGRITY TEST(0,l GPII) GRAVITY FLOW(Check aUthat apply): M8. DAILY VISUAL MONITORING Q 9. BIENNIAL INTEGRITY TEST(0.1 GPH) SECONDARILY CONTAINED PIPING SECONDARILY CONTAINED PIPING PRFSSI.JRIRED PIPING(Check 311 No apply): PRESSURIZED PIPING(Check an that apply): 10. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL Ia. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL ALAR AND(Check oma) ALARMS AND(check one) a. AUTO PUMP SHUT OFF WF1BN A LEAK OCCURS Da AUTO PUMP SHUT OFF WHEN A LEAK OCCURS ©b. AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND RYSTEM ❑b AUTO PUMP SHUT OFF FOR TEAKS,SYSTEM FAILURE AND SVSTF.M DISCONNECTION DISCONNECTION ❑a, NO AUTO PUMP SHUT OFF ❑e NO AUTO PUMP 91 TUT OFF &MrAIJTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)WTTM FLOW SHUT ❑11 AUTOMATIC LEAK DETECTOR OFF OR RESTRICTION ❑lz. ANNUAL INTEGRITY TEST(0.1 GPH) ❑12. ANNUAL INTEGRITY TEST(0.1 GPH) SUCTION/GRAVITY SYSTEM SUCTION/GRAVITY SYSTEM R05"CONTLYUOUS SUMP SENSOR-AUDIBLE AND VISUAL.ALARMS ❑13. CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS EMERGENCY GENERATORS ONLY(Check all that apply) EMERGENCY GF-NERATORS ONLY(Check all Uut apply) 14. CONTINVOUR SUMP SrNSOR WITHOUT AUTO PUMP SHUT OFF ❑14, CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF ,,--AUDIBLE AND VISUAL ALARMS AUDIBLE AND VISUAL.ALARMS W5. AUTOMATIC LINF LRAK DrrECTOR(3.0 GPH TEST)W9_tL0.Q2 FLOW [115. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST) SIM OFF Olt RESTRICTION [116.ANNUAL INTEGRITY TEST(0.1 GPH) ❑16,ANNUAL.INTEGRITY TEST(0,1 GPH) ❑0. DAILY VISUAL CHECK Q 17, DAILY VISUAL CHECK VIII.DISPENSER CONTAINIMENT DISPENSER CONTAINMENT Q 1.FLOAT MECHANISM THAT SHUTS OFF Sl[EAR VALVE 4.DAILY VISUAL CHECK DATE NSTALLED aRR ❑2.CONTINl10110.DISPENSER PAN SENSOR+AUDIBLE AND VISUAL ALARMS ❑5.TRENCH LINER/MONITORING la 3.CONTINUOUS DISPENSER PAN SENSOR WJIH AUTO SHUT OFF FOR Q 6.NONE 469 DISPENSER+AUDIBLE AND VISUAL ALARMS 1X.OWNERIOPERATOR SIGNATURE I wrtify t- die M tion prove heroin is a t,ntw f • IGNATUR ERATO ,f ATE azo NA U t) 471 T OF OVINEPPEWO 472 penia vumb� kfnl use only) if 473 Permit Atmroved(Por k>al tort Doty) 474 Permit Expiration Date(For local um only) 475 UPCF(12/99 revised) Formerly SWRCB Form B