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M � UNDERGROUND STORAGE TANKS - TANK PAGE 2 VI. PIPING CONSTRUCTION Check all that apply) UNDERGROUND PIPING SYS'I'IEMT'YPE> ABOVEGROUND PIPING ® 1. PRESSURE ❑ 2. SUCTION ❑ 3. GRAVITY 458 ❑ I. PRESSURE ❑ 2. SUCTION ❑ 3. GRAVITY CONSTRUCTION ❑ L SINGLE WALL: ❑ 3. LINED TRENCH ❑ 99. OTHER 460 ❑ 1, SINGLE WALL ❑ 95. UNKNOWN MANUFACTURFR ® 2. DOUBLE WALL ❑ 95. UNKNOWN ❑ 2. DOUBLE WALL ❑ 99. O'I'EIER MANUFACTURER TELEFLEX 461 MANUFACTURER TANK Page of 459 462 463 ❑ 1. BART: STEEL. ❑ 6. FRP COMPATIBLE w/100% METTIANOL ❑ 1. 13ARE STEEL ❑ 6. FRP COMPATIBLE W/100%METHANOL. ❑ 2. ST'AINLE'SS STEEL ❑ T GALVANIZED STEEL 1 ❑ Unknown ❑ 2. STAINLESS STEEL ❑ 7. GALVANIZED ❑ 3 PLAST'1C COMPATIBLE W/ CONTENTS ❑ 99. Other ❑ 3. PLASTIC COMPA'T'IBLE W/ CONTENTS STEEL ❑ 8. FLEXIBLE (l-IDPE) ❑ 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 VII' PIPING LEAK DETECTION (Check that 465 all apply) (A description of the monitoring program shall be submitted to the local aeencvl SINGLE. WALL PIPING, 466 PRESSURIZED PIPING (Check all that apply): ❑ 1. ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP SHUT OFF FOR LEAK, SYSTEM FAILURE, AND SYSTEM DISCONNECTION + AUDIBLE AND VISUAL ALARMS. ❑ 2. MONTHLY 0.2 GPII TEST ❑ 3. ANNUAL IN'T'EGRITY TEST (0.1 GPI I) CONVENTIONAL SUCTION SYSTEMS ❑ 5 DAILY VISUAL MONITORING OF PUMPING SYSTEM +TRIENNIAL PIPING INTEGRITY TEST (0. I GPH) SAFE SUCTION SYSTEMS (NO VALUES IN BELOW GROUNDPIPING): ❑ 7. SELF MONITORING GRAVITY FLOW ❑ 9- BIENNIAL INTEGRITY TEST (0.1 GPM) SECONDARILY CONTAINED PIPING PRHSSURIZED PIPING (Check all that apply): 10 CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL ALARMS AND (Check one) Ela. AUTO PUMP SHUI' OFF WIN A LEAK OCCURS ❑ It. AUTO PUMP SHUT OFF FOR LEAKS, SYSTEM FAILURE AND SYSTEM DISCONNECTION Me. NO AUTO PUMP SHUT OFF ® H. AUTOMATIC LINE LEAK DETECTOR (3.0 GPH TEST) WITH FLOW SHUT OFF OR RESTRICTION ® 12. ANNUAL INTEGRITY TEST (0.1 GPH) SUCTION/GRAVITY SYSTEM ❑ 13 CONTINUOUS SUMP SENSOR 4. AUDIBLE AND VISUAL ALARMS EMERGENCY GENERATORS ONLY (Check all that apply) ❑ 14. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SIIUTOFF " AUDIBLE AND VISUAL ALARMS ❑ 15. AUTOMATIC LINE LEAK DETECTOR (3A GPII TEST) WITI-LOUT FLOW SHUT OFF OR RESTRICTION ❑ 16. ANNUAL INTEGRITY'I'EST (0.1 GPII) ❑ 17. DAILY VISUAL CHECK SINGLE WALL PIPING 467 13RLSSURIZED PIPING (Check all that apply): ❑ 1. ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP SI4UT OFF FOR LEAK, SYSTEM FAILURE, AND SYSTEM DISCONNECTION + AUDIBLE AND VISUAL ALARMS. ❑ 2. MONTHLY 0.2 GPII TEST' ❑ 3. ANNUAL INTEGRITY TEST (0. I GPH) ❑ 4. DAILY VISUAL CHECK CONVENTIONAL SUCTION SYSTEMS (Check all that apply) ❑ 5. DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM ❑ 6. TRIENNIAL INTEGRITY TEST (0.1 GPH) SAFE SUCTION SYSTEMS (NO VALVES IN BELOW GROUND PIPING): ❑ 7. SELF MONITORING GRAVITY FLOW (Check all that apply): ❑ 8. DAILY VISUAL MONITORING ❑ 9. BIENNIAL INTEGRITY TEST (0.1 GPH) SECONDARILY CONTAINED PIPING PRESSURIZED PIPING (Check all that apply) 10. CON'T'INUOUS TURBINE SUMP SENSOR WITH AUDIBLE ANIS VISUAL ALARMS AND (Check one) ❑ a AUI'O PUMP SHUT OTT WHEN A LEAK OCCURS ❑ b AUTO PUMP SHAT OFF FOR LEAKS, SYSTEM FAILURE AND SYSTEM DISCONNECTION ❑c NO AUTO PUMP SHUT OFF ❑ 11. AUTOMATIC LEAK DETEC'T'OR ❑ 12. ANNUAL INTEGRITY TEST (0.1 GPH) SUCTION/GRAVITY SYSTEM ❑ 13. CONTINUOUS SUMP S13NSOR + AUDIBLE AND VISUAL ALARMS EMERGENCY GENERATORS ONLY (Check all that apply) ❑ 14. CONTINUOUS SUMP SENSOR WI_I_}IOUT AUTO PUMP SHUTOFF " AUDIBLE AND VISUAL ALARMS ❑ 15. AUTOMATIC LINE LEAK DETECTOR (3.0 GPH TEST) ❑ 16. ANNUAL IN-IEGRITY TEST (0.1 GPH) ❑ 17. DAILY VISUAL CHECK VIII. DISPENSER CONTAINMENT DISPENSER CONTAINMENT ® 1. FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE DATE INSTALLED 468 ❑ 2. CONTINUOUS DISPENSER PAN SENSOR -I AUDIBLE AND VISUAL ALARMS 1995 ❑ 3 CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUTOFF FOR DISPENSER + AUDIBLE AND VISUAL, ALARMS IX. OWNER/OPERATOR SIGNATURE I certify that the information provided herein is true and accurate to the best of my knowledge. SIGN4TURE O OWNS OP RATOR DATE j--/1-03 OF OWNER/ PRATOR (print) ITLE OF SANDY EDWARDS Number (For local use only) 473 Permit Approved (For local use only) [14. DAILY VISUAL CHECK ❑ 5. TRENCH LINER / MONITORING ❑ 6. NONE Permit rxpt7rafi-of-7D`at77For locai use 469 475 UPCF (1/99 revised) Formerly SWRCB Form B