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ONIFIED PROGRAM CONSOLIDATED FOR$ er+ UNDERGROUND STORAGE TANKS - TANK PAGE 2 VI.PIPING CONSTRUCTION(Cheek all that apply) Pagc 3 of 10 UNDERGROUND PIPING ABOVEGROUND PIPING SYSTEM TYPE 1.PRESSURE ❑ 2.SUCTION ❑ 3.GRAVITY 458 PRESSURE ❑ 2.SUCTION ❑ 3.GRAVITY 459 CONSTRUCTION ❑ 1.SINGLE WALL Q 3.LINED TRENCH ❑99.OTHER 460 1.SINGLE WALL ❑ 95.UNKNOWN /� 462 ❑ 2.DOUBLE WALL ❑ 95.UNKNOWN ❑ 2.DOUBLE WALL El 99.OTH R MANUFACTURER 461 MANUFACTURER 463 ❑ 1.BARE STEEL ❑6.FRP COMPATIBLE wi 100%METHANOL ❑ 1.BARE STEEL ❑ 6.FRP COMPATIBLE w/100%METHANOL ❑ 2.STAINLESS STEEL ❑ 7.GALVANIZED STEEL ❑ 2.STAINLESS STEEL ❑ 7.GALVANIZED STEEL ASTIC COMPATIBLE W/CONTENTS 95.UNKNOWN ❑ P STIC COMPATIBLE W/CONTENTS ❑ nc r n rtrwrnxxret FIBERGLASS El8.FLEXIBLE(HDPE) El99.OTHER 1FIBERGLASS ❑ 8.FLEXIBLE(HDPE) ❑ 99.OTHER ❑ 5.STEEL W/COATING ❑ 9.CATHODIC PROTECTION 464 ❑ 5.STEEL W/COATING ❑ 9.CATHODIC PROTECTION 465 VII.PIPING LEAK DETECTION(Check all that apply)(A description of the monitoring program shall be submitted to the local agency.) UNDERGROUND PIPING ABOVEGROUND PIPING SINGLE WALL PIPING 466 SINGLE WALL PIPING 467 PURIZED PIPING(Check all that apply): PRESSURIZED PIPING(Cheek all that apply): 1.ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP SHUT OFF ❑ 1.ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP SHUT OFF FOR LEAK,SYSTEM FAILURE,AND SYSTEM DISCONNECTION+AUDIBLE AND FOR LEAK,SYSTEM FAILURE,AND SYSTEM DISCONNECTION+AUDIBLE AND VISUAL ALARMS. VISUAL ALARMS. -MONTHLY 0.2 GPH TEST 3.ANNUAL INTEGRITY TEST(0.1 GPH} ❑ 2•MONTHLY 0.2 GPH TEST ❑ 3.ANNUAL INTEGRITY TEST(0.1 GPH) R ❑ 4.DAILY VISUAL CHECK CONVENTIONAL SUCTION SYSTEMS CONVENTIONAL SUCTION SYSTEMS(Check all that apply) ❑ 5.DAILY VISUAL MONITORING OF PUMPING SYSTEM+TRIENNIEAL PIPING ❑ 5.DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM INTEGRITY TEST(0.1 GPH) ❑ 6.TRIENNIAL INTEGRITY TEST(0.1 GPH) SAFE SUCTION SYSTEMS(NO VALUES IN BELOW GROUNDPIPING): SAFE SUCTION SYSTEMS(NO VALUES IN BELOW GROUNDPIPING): ❑ 7.SELF MONITORING ❑ 7.SELF MONITORING GRAVITY FLOW ❑ 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 appy): 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(Cheek one) VLtd .AUTO PUMP SHUT OFF WHEN A LEAK OCCURS E] 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)WITH FLOW SHUT OFF OR ❑ 11 AUTOMATIC LEAK DETECTOR RESTRICTION ❑ 12.ANNUAL INTEGRITY TEST(0.1 GPH) ❑ 12.ANNUAL INTEGRITY TEST(0.1 GPH) YSU ION/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 appy) EMERGENCY GENERATORS ONLY(Check all that apply) ❑ 14.CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF* ❑ 14.CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF' AUDIBLE AND VISUAL ALARMS AUDIBLE AND VISUAL ALARMS ❑ I5.AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)WITHOUT FLOW ❑ 15.AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)WITHOUT FLOW SHUT OFF OR RESTRICTION 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 ❑ 1.FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE ❑ 4.DAILY VISUAL CHECK DATE INSTALLED 468 ❑2.CONTINUOUS DISPENSER PAN SENSOR+AUDIBLE AND VISUAL ALARMS ® 5.TRENCH LINER/MONITORING ❑ 3.CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR ❑ 6.NONE DISPENSER+AUDIBLE AND VISUAL ALARMS 469 LK.OWNER/OPERATOR SIGNATURE 1 certify that the information provided herein is true and aeeurate to the best of my knowledge. SIGNATU)�� PERAT _ DATE y� 470 NAME OF OWNER/OPERATOR(prim[) TITLE OF OWNER/OPERATOR ^1/ 6 lr b C-RP- V` Z Ac 471 -k41'6 JzA-' 472 Permit Number(For local use only) 473 Permit Approved(For local use only) 474 Permit Expiration Date(For local use only) 475 PT0004872 EE0000646 12/31/2001 UPCF(12/99 revised) -TDi N �i%s t' aP 1/wNowi,r