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' LRFIED PROGRAM CONSOLIDATED FORW TANKS UNDERGROUND STORAGE TANKS - TANK PAGE 2 Pa e_of_ VI.PIPING CONSTRUCTION(Check au tent I) UNDERGROUND PIPING ABOVEGROUND PIPING SYSTEM TYPE I.PRESSURE ❑2.SUCTION ❑3.GRAVITY 458. ❑ I.PRESSURE [12.SUCTION ❑3.GRAVITY 459. CONSTRUCTION/ ❑1.SINGLE WALL ❑3.LINED TRENCH ❑99.OTHER 460. ❑ I.SINGLE WALL ❑95.UNKNOWN J6'- MANUFACTURER tt 2.DOUBLE WALL ❑95.UNKNOWN ❑2.DOUBLE WALL 99.OTHER MANUFACTURER A*%ILMO" 4 C)( 461. MANUFACTURER 463. ❑ I.BARE STEEL Ed 6.FRP COMPATIBLE W/100%METHANOL ❑ I.BARE STEEL ❑6.FRP COMPATIBLE W/100%METHANOL ❑2.STAINLESS STEEL [17.GALVANIZED STEEL -1 ❑2.STAINLESS STEEL ❑7.GALVANIZED STEEL ❑3.PLASTIC COMPATIBLE WITH CONTENTS ❑95.UNKNOWN ❑3.PLASTIC COMPATIBLE W/CONTENTS ❑8.FLEXIBLE(HDPE) ❑99.OTHER ❑4.FIBERGLASS ❑8.FLEXIBLE(HDPE) ❑99.OTHER ❑4.FIBERGLASS ❑9.CATHODIC PROTECTION ❑5.STEEL W/CO.ATING [19.CATHODIC PROTECTION 464. ❑5.STEEL W/COATING ❑95.UNKNOWN 465. VII.PIPING LEAK DETECTION(Check a0 that apply) A descri tion of the monitoring program shall be submitted to the local agency.) UNDERGROUND PIPING ABOVEGROUND PIPING SINGLE WALL PIPING 466. SINGLE WALL PIPING 467. PRESSURIZED PIPING(Check all that apply): PRESSURIZED PIPING(Check all that apply): 01, 1 OFF FOR LEAK,SYSTEM NIC LINE LEAK S FAILURE,R 3.0 GPH TEST WITH E 1 DETECTOR. ELECTRONIC LINE LEAK LURE,AND SYSTEM D SLEAK,CONNCTION PUMP ❑ SHUT OFF FOR AK,SYS SHUT-OFF FAILURE,AND SYSTEM DISCONNECTION +AUDIBLE AND VISUAL ALARMS. +AUDIBLE AND VISUAL ALARMS. [_12. MONTHLY 0.2 GPH TEST ❑2. MONTHLY 0.2 GPH TEST ❑3. A". UAL INTEGRITY TEST(0.1 GPH) [_13. ANNUAL INTEGRITY TEST(0.1 GPH) ❑4. DAILY VISUAL CHECK CONVENTIONAL SUCTION SYSTEMS CONVENTIONAL SUCTION SYSTEMS(Check all that apply) ❑5. DAILY VISUAL MONITORING OF PUMPING SYSTEM+TRIENNIAL PIPING [15. DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM INTEGRITY TEST(0.1 GPH) SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): ❑6. TRIENNIAL INTEGRITY TEST(0.1 GPH) ❑7. SELF MONITORING SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): GRAVITY FLOW [17. SELF MONITORING ❑9. BIENNIAL INTEGRITY TEST(0.1 GPH) GRAVITY FLOW(Check all that apply): ❑8. DAILY VISUAL MONITORING [39, 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 WITH AUDIBLE AND VISUAL 10. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL ALARMS AND(Check one) ALARMS AND(Check one) ❑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 DISCONNECTION PUMPSHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM DISCONNECTION ❑c. NO AUTO PUMP SHUT OFF ❑c. NO AUTO PUMP SHUT OFF (� 11. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)WITH FLOW SHUT ❑11. AUTOMATIC LEAK DETECTOR OFF OR RESTRICTION ❑ 12. ANNUAL INTEGRITY TEST(0.1 GPH) ❑ 12. ANNUAL INTEGRITY TEST(0.1 GPH) SUCTION/GRAVITY SYSTEM SUCTION/GRAVITY SYSTEM ❑ 13. 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) ❑ l4. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF ❑14. CONTINUOUS SUMP IBLE USUAL SENSOR WITHOU AUTO PUMP SHUT OFF AUDIBLE AND VISUAL ALARMS ❑ LARMS 15. AUTOMATIC LINE LEAK DETECTOR (3.0 GPH TEST) WITHOUT FLOW ❑15. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST) SHUT OFF OR RESTRICTION ❑ 16. ANNUAL INTEGRITY TEST(0.1 GPH) ❑ 16. ANNUAL INTEGRITY TEST(0.1 GPH) ❑ 17. DAILY VISUAL CHECK ❑ 17. DAILY VISUAL CHECK VIII.DISPENSER CONTAINMENT DISPENSER CONTAINMENT 468. ❑1. FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE [34. DAILY VISUAL CHECK 469 DATE INSTALLED ❑2. CONTINUOUS DISPENSER PAN SENSOR+AUDIBLE AND VISUAL ALARMS ❑5. TRENCH/LINER MONITORING 0 3 IQ 3. CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR ❑6. NONE DISPENSER+AUDIBLE AND VISUAL ALARMS IX.OWNER/OPERATOR SIGNATURE I certify that the information provided herein is truejand accurate to the best of my knowledge. SIGNATURE OF DATE: azo. oRT c.i :� 5� 6 �l6 oT 472. NAME OF (print): TITLE C 0 Wr Q XLT02 j1AIC41A.6L E A L r-4 Permit Number(Agency use only) 473. 1 Permit Approved By(Agency use only) 474. Permit Expiration Date(Agency use only) 475. UPCF hwfwre-b(1/99)-3/4 http://www.unidocs.org Rev.02/16/00