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NIFIED PROGRAM CONSOLIDATED RPM TANK UNDERGROUND STORAGE TANKS - TANK PAGE 2 VLPIPING>CONSTRUCTION,(check soPale- of UNDERGROUND PIPING ABOVEGROUND PIPING SYSTEM TYPE 1.PRESSURE ❑2.SUCTION ❑3.GRAVITY 458 ❑1.PRESSURE ❑2. SUCTION ❑3.GRAVITY 459 CONSTRUCTION 1 1.SINGLE WALL ❑3.LINED TRENCH ❑99.OTHER 460 [11.SINGLE WALL ❑95.UNKNOWN 462 MANUFACTURER ❑2.DOUBLE WALL ❑95.UNKNOWN ❑2.DOUBLE WALL ❑99.OTHER MANUFACTURER 461 MANUFACTURER 463 ❑1.BARE STEEL ❑6.FRP COMPATIBLE wntX1% METHANOL ❑1.BARE STEEL ❑6.FRP COMPATIBLE Wn00%wnwiloL ❑2.STAINLESS STEEL ❑7.GALVANIZED STEEL ❑UKNOWN ❑2. STAINLESS STEEL ❑7.GALVANIZED STEEL ❑3.PLASTIC COMPATIBLE W/CONTENTS ❑99. OTHER ❑3. PLASTIC COMPATIBLE Wl CONTENTS ❑8.FLEXIBLE(HDPE) ❑99. OTHER 4.FIBERGLASS ❑8.FLEXIBLE(HOPE) ❑4. FIBERGLASS ❑9.CATHODIC PROTECTION ❑5.STEEL W/COATING ❑9.CATHODIC PROTECTION 464 1 ❑5. STEEL W/COATING ❑95.UNKNOWN 465 Vit.FWNall aket �. UNDERGROUND PIPING ABOVEGROUND PIPING SINGLE WALL PIPING 466 SINGLE WALL PIPING 467 PRESSURIZED PIPING(Chad a1 eutapptyt PRESSURIZED PIPING(Check a9 that apply): [31. ELECTRONIC LINE LEAK DETECTOR 3.0 GPM TEST WITH AUTO PUMP SHUT OFF FOR [31. ELECTRONIC UNE LEAK DETECTOR 3.0 GPH TEST NTH AUTO PUMP SHUT OFF FOR LEAK SYSTEM FAILURE,AND SYSTEM DISCONNECTION+AUDIBLE AND VISUAL LEAK,SYSTEM FAILURE,AND SYSTEM DISCONNECTION+AUDIBLE AND VISUAL ALARMS. ALAIM. [32. MONTHLY 0.2 GPH TEST ❑2. MONTHLY 0.2 GPH TEST 3. ANNUAL INTEGRITY TEST(0.1GPH) ❑3. ANNUAL INTEGRITY TEST(0.1GPH) ❑4. DAILY VISUAL CHECK CONVENTIONAL SUCTION SYSTEMS CONVENTIONAL SUCTION SYSTEMS(Check a1 that apply) [35. DAILY VISUAL MONITORING OF PUMPING SYSTEM+TRIENNIAL PIPING INTEGRITY TEST(0.1 GPH) ®5. DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM SAFE SUCTION SYSTEMS(NO VALUES IN BELOW GROUNDPIPING): ❑6. TRIENNIAL INTEGRITY TEST(0.1 GPH) ❑7. SELF MONITORING SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): GRAVITY FLOW ❑7. SELF MONITORING [39. BIENNIAL INTEGRITY TEST(0.1 GPH) GRAVITY FLOW(Check at that apply): I i I C38 _Om 'VIS 1Ak NON',ONNG ❑9. BIENNIAL INTEGRITY TEST(i;.i G{14) SECONDARILY CONTAINED PIPING SECONDARILY CONTAINED PIPING PRESSURIZED PIPING(Check a8 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 [3b. 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)WITH FLOW SHUTOFF OR RESTRICTION ❑11. AUTOMATIC LEAK DETECTOR ❑12. ANNUAL INTEGRITY TEST(0.1 GPH) [312. ANNUAL INTEGRITY TEST(0.1 GPH) SUCTION/GRAVITY SYSTEM SUCTION/GRAVITY SYSTEM [113. 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) [314. CONTINUOUS SUMP SENSOR W TI HOUT 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 RESTRICTION ❑15. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST) ❑16. ANNUAL INTEGRITY TEST(0.1 GPH) ❑16. ANNUAL INTEGRITY TEST(0.1 GPH) ❑17. DAILY VISUAL CHECK [317. DAILY VISUAL CHECK Vill.DISPENSER CONTAINMENT DISPENSER CONTAINMENT [31. FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE ❑4.DAILY VISUAL CHECK DATE INSTALLED 466 ❑2. CONTINUOUS DISPENSER PAN SENSOR+AUDIBLE AND VISUAL ALARMS ❑5.TRENCH LINER I MONITORING fIR3. CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR DISPENSER AUDIBLE AND VISUAL ALARMS ❑6.NONE 469 IX.OWNEPJOPERATOR SIGNATURE I Certify that the information provided herein is true and t t f my knovAedge. SIGNATURE OF OWNER/OPERATOR DATE 470 NAME OF QWNERJOPRATOR nnt) $q TLE OF OWNERIOPERATOR 472 Pemul NUmoer(For local use only) 473 Permit Approveo(Fox local use only) Permit Expiration Date(For local use only) 475 UPCF(1/99 revised) Formerly SWRCB Form B