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BILLING PRE 2019
Environmental Health - Public
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2300 - Underground Storage Tank Program
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PR0516526
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BILLING PRE 2019
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Entry Properties
Last modified
11/16/2022 12:00:02 PM
Creation date
11/1/2018 9:45:27 AM
Metadata
Fields
Template:
EHD - Public
ProgramCode
2300 - Underground Storage Tank Program
File Section
BILLING
FileName_PostFix
PRE 2019
RECORD_ID
PR0516526
PE
2361
FACILITY_ID
FA0012659
FACILITY_NAME
LOVE'S COUNTRY STORES OF CALIF #223
STREET_NUMBER
1553
STREET_NAME
COLONY
STREET_TYPE
RD
City
RIPON
Zip
95366
APN
24534024
CURRENT_STATUS
01
SITE_LOCATION
1553 COLONY RD
P_LOCATION
05
P_DISTRICT
005
QC Status
Approved
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EHD - Public
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UNIFIED PROGRAM CONSOLIDATED FORM <br /> TANKS <br /> UNDERGROUND STORAGE TANKS -TANK PAGE 2 <br /> VI.PIPING CONSTRUCTION(Chock aB that apply) <br /> UNDERGROUND PIPING ABOVEGROUNO PIPING <br /> SYSTEM TYPE 1 PRESSURE ❑ 2 SUCTION ❑ 3 GRAVITY ❑ 1 PRESSURE ❑ 2. SUCTION ❑ 3 GRAVITY <br /> CONSTRUCTION/ ❑ I SINGLE WALL ❑ 1 LINED TRENCH C199 OTHER ❑ 1 SINGLE WALL C395 UNKNOWN <br /> MANUFACTURER DOUBLE WALL C�9S UNKNOWN ❑ 2. DOUBLE WALL C399 OTHER <br /> MANUFACTURER El^V(r0 N Geo f/ "- MANUFACTURER <br /> ❑ 1 BARE STEEL C3 FRP COMPATIBLE W/100%METHANOL C31. BARE STEEL C3 D FRP COMPATIBLE W/100%METHANOL <br /> MATERIALS AND ❑ 2. STAINLESS STEEL ❑ 7. GALVANIZED STEEL ❑ 2. STAINLESS STEEL ❑ 7. GALVANIZED STEEL <br /> CORROSION <br /> PROTECTION ❑ 3 PLASTIC COMPATIBLEHATH NTENTS [:195 UNKNOWN C33 PLASTIC COMPATIBLE WITH CONTENTS Ela FLEXIBLE(MOPE) 99 OTHER <br /> C34 FIBERGLASS E FLEXIBLE(HOPE) ❑99 OTHER. ❑ 4 FIBERGLASS , . ❑ 9 CATHODIC PROTECTION <br /> ❑ 5 STEEL W/COATING ❑ 9 CATHODIC PROTECTION ❑ 5 STEEL Wl COATING ❑95 UNKNOWN <br /> VII.PIPING LEAK DETECTION(Chock fl that appy) <br /> UNDERGROUND PIPING ABOVEGROUNO PIPING <br /> SINGLE WALL PIPING <br /> SINGLE WALL PIPING PRESSURIZED PIPING(Check ak that apply). <br /> PRESSURIZED PIPING(Check as that apoy) <br /> C3 I ELECTRONIC LINE LEAK DETECTOR 3 0 GPM TEST WITH AUTO PUMP SMUT OFF FOR ❑ 1. ELECTRONIC LINE LEAK DETECTOR].0 GPM TEST WITH AUTO PUMP SMUT OFF FOR LEAK, <br /> LEAK,SYSTEM FAILURE,AND SYSTEM DISCONNECTION•AUDIBLE AND VISUAL SYSTEM FAILURE.AND SYSTEM DISCONNECTION•AUDIBLE AND VISUAL ALARMS <br /> ALARPAS ❑ 2 MONTHLY 0.2 GPM TEST <br /> ❑ 2. MONTHLY 0 2 GPM TEST ❑ 3. ANNUAL INTEGRITY TEST(0.1 GPM) <br /> ❑ 3 ANNUAL INTEGRITY TEST(0 1 GPM) ❑.4. DAILY VISUAL CHECK <br /> CONVENTIONAL SUCTION SYSTEMS(Chock as that spPy): <br /> CONVENTIONAL SUCTION SYSTEMS <br /> ❑ 5 DAILY VISUAL MONITORING OF PUMPING SYSTEM-TRIENNIAL PIPING INTEGRITY <br /> ❑ 5 DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM <br /> TEST(0 1 GPM) ❑ B TRIENNIAL INTEGRITY TEST(0.1 GPM) <br /> SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING) SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING) <br /> ❑ 7 SELF MONITORING ❑ 7. SELF MONITORING <br /> GRAVITY FLOW GRAVITY FLOW(Chock all that apply)' <br /> ❑ 9 BIENNIAL INTEGRITY TEST(0 1 GPM) ❑ E DAILY VISUAL MONITORING <br /> ❑ 9 BIENNIAL INTEGRITY TEST(O 1 GPM) <br /> SECONDARILY CONTAINED PIPING <br /> SECONOA91LY CONTAINED PIPING PRESSURIZED PIPING(Chock aY that appy)' <br /> PRESSURIZED PIPING(Check all that apply)' <br /> 10 CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL ALARMS AND 10.CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL ALARMS AND(check one) <br /> ( n'pA ono) ❑ a. AUTO PUMP SHUT OFF WHEN A LEAK OCCURS <br /> AUTO PUPAP SMUT OFF WHEN A LEAK OCCURS <br /> ❑ o AUTO PUMP SHUT OFF FOR LEAKS.SYSTEM FAILURE AND SYSTEM ❑ b AUTO PUMP SMUT OFF FOR LEAKS.SYSTEM FAILURE AND SYSTEM DISCONNECTION <br /> DISCONNECTION <br /> c. NO AUTO PUMP SMUT OFF <br /> C1 C. NO AUTO PUMP SMUT OFF <br /> 11 AUTOMATIC LINE LEAK DETECTOR(3 0 GPM TEST)WITH FLOW SHUT OFF OR [D1 t AUTOMATIC LEAK DETECTOR <br /> ❑ <br /> RESTRICTION <br /> C1 12 ANNUAL INTEGRITY TEST(0 1 GPM) C112. ANNUAL INTEGRITY TEST(0.1 GPM) <br /> SUCTION;GRAVITY SYSTEM SUCTION/GRAVITY SYSTEM. <br /> ❑ 13 CONTINUOUS SUMP SENSOR•AUDIBLE AND VISUAL ALARMS ❑ 13. CONTINUOUS SUMP SENSOR•AUDIBLE AND VISUAL ALARMS <br /> EMERGENCY GENERATORS ONLY(Check as that aptly) EMERGENCY GENERATORS ONLY(Chock alf that appy) <br /> ❑ 14 CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF-AUDIBLE AND ❑ 14 ALARMS CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP.SHUT OFF•AUDIBLE AND VISUAL <br /> VISUAL ALARMS <br /> ❑ 15 AUTOMATIC LINE LEAK DETECTOR(3.0 GPM TEST)WTHOUT FLOW SHUT OFF OR ❑ 15. AUTOMATIC LINE LEAK DETECTOR(30 GPM TEST) <br /> RESTRICTION <br /> ❑ 15, ANNUAL INTEGRITY TEST(0 1 GPM) ❑ td. ANNUAL INTEGRITY TEST(0.1 GPM) <br /> ❑ 17. DAILY VISUAL CHECK ❑ 17. DAILY VISUAL CHECK <br /> VIIL DISPENSER CONTAINMENT <br /> DISPENSER CONTAINMENT 0;,,aFL0AT MECHANISM THAT SHUTS OF�SMEAR VALVE C34. DAILY VISUAL CHECK <br /> [:1 S. TRENCH LINER t MONITORING <br /> DATE INSTALLED 2 CONTINUOUS DISPENSER PAN SENSOR AUDIBLE AND VISUAL ALARMS <br /> ❑ 3 CONTINUOUS OISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR DISPENSER•AUDIBLE AND VISUAL ALARMS ❑ 0. NONE <br /> IX OWNER)OPERATOR SIGNATURE <br /> I cerby Mal ate IMumakon Provided honor Is true aha accyrau to"bast Of my khawM09e <br /> SIGNATURE Q F OWnNERIOPERATOR NS `7 111%;x: � sii'"_�JTDATE <br /> L7 -2 7—p o <br /> NAME OF OWNER:OPERAT R(P-0TITLE OF OWNER/OPERATOR <br /> Perms Number(Fw local uaa oMy) <br /> PwM.1 AOp—W(Fw local uae wky) Pomrt EApw&tan Data(For local wa oNy) <br /> Formerty SWRC8 Form B <br /> CLIPAFORM(4/99) <br />
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