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r IFIED PROGRAM CONSOLIDATED FOfjV l (Sr/ p.7 �� p [[ `-� TANK UNDERGROUND STORAGE TANKS - TANK PAGE 2 VL PIPING CONSTRUCTION (Check all that apply) Page _ of _ UNDERGROUND PIPING ABOVEGROUND PIPING SYSTEM TYPE ®1. PRESSURE ❑ 2. SUCTION ❑ 3. GRAVITY 458 ❑ 1. PRESSURE ❑ 2. SUCTION ❑ 3. GRAVITY 459 CONSTRUCTION / ❑ 1. SINGLE WALL ❑ 3. LINED TRENCH ❑ 99. OTHER 460 ❑ 1. SINGLE WALL ❑ 95. UNKNOWN 462 MANUFACTURER ® 2. DOUBLE WALL ❑ 95. UNKNOWN ❑ 2. DOUBLE WALL ❑ 99. OTHER MANUFACTURER TELEFLEX 461 MANUFACTURER 463 ❑ 1. BARE STEEL ❑ 6. FRP COMPATIBLE w/100% METHANOL ❑ 1. BARE STEEL ❑ 6. FRP COMPATIBLE W110D%METHANOL ❑ 2. STAINLESS STEEL ❑ 7. GALVANIZED STEEL ❑ UKNOWN ❑ 2. STAINLESS STEEL ❑ 7. GALVANIZED STEEL ❑ 3. PLASTIC COMPATIBLE W/ CONTENTS ❑ 99. OTHER ❑ 3. PLASTIC COMPATIBLE W/ CONTENTS ❑ 8. FLEXIBLE (HDPE) ❑ 99. OTHER ® 4. FIBERGLASS ❑ 8. FLEXIBLE (HDPE) ❑ 4. FIBERGLASS ❑ 9. CATHODIC PROTECTION ❑ 5. STEEL W/COATING ❑ 9. CATHODIC PROTECTION 464 ❑ 5. STEEL W/COATING ❑ 95. UNKNOWN 465 VII. PIPING LEAK DETECTION (Check all that apply) (A description of the monitoring shall be submitted to Me local UNDERGROUND PIPING ABOVEGROUND PIPING SINGLE WALL PIPING 466 SINGLE WALL PIPING 467 PRESSURIZED PIPING (Check all thataWy): PRESSURIZED PIPING (Check all that apply): ❑ 1. ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TESTIyyTHH AUTO PUMP SHUT OFF FOR [11. ELECTRONIC UNE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP SHUT OFF FOR LEAK, SYSTEM FAILURE, AND SYSTEM DISCONNECTION +AUDIBLE AND VISUAL LEAK, SYSTEM FAILURE, AND SYSTEM DISCONNECTION + AUDIBLE AND VISUAL ALARMS. ALARMS. ❑ 2. MONTHLY 0.2 GPH TEST ❑ 2. MONTHLY 0.2 GPH TEST ❑ 3. ANNUAL INTEGRITY TEST (0.1GPH) ❑ 3. ANNUAL INTEGRITY TEST (0.1 GPH) [34. DAILY VISUAL CHECK CONVENTIONAL SUCTION SYSTEMS CONVENTIONAL SUCTION SYSTEMS (Check all that apply) [35. DAILY VISUAL MONITORING OF PUMPING SYSTEM +TRIENNIAL PIPING INTEGRITY ❑ 5. DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM TEST (0.1 GPH) SAFE SUCTION SYSTEMS (NO VALUES IN BELOW GROUNDPIPING): ❑ 6. TRIENNIAL INTEGRITY TEST (0.1 GPH) [17. SELF MONITORING SAFE SUCTION SYSTEMS (NO VALVES IN BELOW GROUND PIPING): GRAVITY FLOW ❑ 7. SELF MONITORING ❑ 9. BIENNIAL INTEGRITY TEST (0.1 GPH) GRAVITY FLOW (Check all that apply): ❑ 8. DAILY VISUAL MONITORING ❑ 9. BIENNIAL INTEGRITY TEST (0.1 GPH) SECONDARILY CONTAINED PIPING SECONDARILY CONTAINED PIPING PRESSURIZED PIPING (Check all that apply): PRESSURIZED PIPING (Check all that apply): 10. CONTINUOUS TURBINE SUMP SENSOR )pQ AUDIBLE AND VISUAL ALARMS AND 10. CONTINUOUS TURBINE SUMP SENSOR M AUDIBLE AND VISUAL ALARMS AND (Checkone) (ChK kom) ❑ 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 ®c. NO AUTO PUMP SHUT OFF ❑c NO AUTO PUMP SHUT OFF ®11. AUTOMATIC LINE LEAK DETECTOR (3.0 GPH TEST) NTH FLOW SHUTOFF OR ❑ 11. AUTOMATIC LEAK DETECTOR RESTRICTION 12. ANNUAL INTEGRITY TEST (0.1 GPH) ❑ 12. ANNUAL INTEGRITY TEST (0.1 GPH) SUCTION/GRAVITY SYSTEM SUCTION/GRAVITY SYSTEM [313. 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) ❑ 14. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF +AUDIBLE AND ❑ 14. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF +AUDIBLE AND VISUAL ALARMS VISUAL ALARMS ❑ 15. AUTOMATIC LINE LEAK DETECTOR (3.0 GPH TEST) WITHOUT FLOW SHUT OFF OR ❑ 15. AUTOMATIC LINE LEAK DETECTOR (3.0 GPH TEST) RESTRICTION ❑ 16. ANNUAL INTEGRITY TEST (0.1 GPH) [116. ANNUAL INTEGRITY TEST (0.1 GPH) ❑ 17. DAILY VISUAL CHECK ❑ 17. DAILY VISUAL CHECK VIII. DISPENSER CONTAINMENT DISPENSER 01. FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE ❑ 4. DAILY VISUAL CHECK CONTAINMENT DATE INSTALLED 468 ❑ 2. CONTINUOUS DISPENSER PAN SENSOR + AUDIBLE AND VISUAL ALARMS ❑ 5. TRENCH LINER / MONITORING 1995 ❑ 3. CONTINUOUS DISPENSER PAN SENSORIVI�TH AUTO SHUT OFF FOR DISPENSER + ❑ 6. NONE 469 AUDIBLE AND VISUAL ALARMS DL OWNER/OPERATOR SIGNATURE I certify that the Information p id n is true and a rate to the best of my knowledge. SIGNATURE OF O TOR DATE 470 ia 4/28/07 NAME OF OW P TOR (print) TITLE OF OWNER/OPERATOR 472 Cindy Hughes Madrid General Manager, Retail Services it Number (For local use only) 473 Permit Approved (For local use only) Permit Expiration Date (For local use only) 475 E UPCF (12/99 revised) Formedv SWRCB Form B