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,, I D PROGRAM CONSOLIDATED FO 6-5-0.5 <br /> TANK <br /> UNDERGROUND STORAGE TANKS- TANK PAGE 2(�R3 G 0 3 <br /> VL PING CONSTRUCTION Chock tlihat page 6 at 8 <br /> UNDERGROUND PIPING ABOVEGROUND PIPING <br /> SYSTEM TYPE 0 1.PRESSURE 0 2.SUCTION 0 3.GRAVITY 4M 0 L PRESSURE 0 2. SUCTION 0 3.GRAVITY 459 <br /> cONS'IRUCBON ®1.SINGLE WALL ®3.LINED TRENCH ❑99.OTHER a6o I.SINGLE WALL 95.UNKNOWN a6z <br /> MANUFACTURER 0 2.DOUBLE WALL 0 95.UNKNOWN 0 2.DOUBLE WALL 0 99.OTHER <br /> MANUFACTURER A Smith 461 MANUFACTURER <br /> 0 1.BARE STEEL 0 6.FRP COMPATIBLE w/jeep/. w9NANOL 0 L BARE STEEL ❑6.FRP COMPATIBLE W/1 WX ME]fIgNOL <br /> 0 2.STAINLESS STEEL 0 7.GALVANIZED STEEL 0 Unknown 0 2. STAINIMS STEEL <br /> ❑7.GALVANIZED STEEL <br /> 0 3.PLAST7C COMPATIBLE W/CONTENTS 0 99. Other 03. PLASTIC COMPATIBLE W/CONTENTS 0 8.FLEXIBLE(HDPE) 0 99. OTHER <br /> 0 4.FBERGLASS 0 E.FLEXIBLE(HDPE) 0 4. FIBERGLASS 0 9.CATHODIC PROTECTION <br /> 0 5.STEEL W/COATING ®9.CATHODIC PROTECTION 461 0 5. STEEL W/COATING 0 95.UNKNOWN 46s <br /> VII.PIPING LEARDETECTION Checktlfltt A -fta moneorvi -hall ba..bInWPd w*.bowl ) <br /> UNDERGROUND PIPING ABOVEGROUND PIPING <br /> SINGLE WALL PIPING 466 SINGLE WALL PIPING 467 <br /> PRESSURIZED PIPING(Cheek ail tam appy): PRESSURIZED PIPING(Ch kall that apply) <br /> ®I.ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP SHUT 0 1. ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST AUTO POMP <br /> OFF FOR LEAK,SYSTEM FAILURE,AND SYSTEM DISCONNECTION+ SHOT OFF FOR LEAK,SYSTEM FAILURE,AND SYSTEM DISCONNECTION+ <br /> AUDIBLE AND VISUAL ALARMS. AUDIBLE AND VISUAL ALARMS. <br /> ®2.MONTHLY 0.2 GPH TEST 0 2. MONTHLY 0.2 GPH TEST <br /> ®3.ANNUAL INTEGRITY TEST(0.1GPM 0 3.ANNUAL INTEGRITY TEST(0.IOPH) <br /> 04. DAILY VISUAL CHECK <br /> CONVENTIONAL SUCTION SYSTEMS CONVENTIONAL SUCTION SYSTEMS(Clark all that appy) <br /> 0 5.DAILY VISUAL MONITORING OF PUMPING SYSTEM+TRIENNIAL PIPING <br /> INTEGRITY TEST(0.1 GPH) 0 5, DAILY VISUAL MONITORING OFPIPING AND PUMPING SYSTEM <br /> SAFE SUCTION SYSTEMS(NO VALUES IN BELOW GROUND PIPING): 0 6. TRIENNIAL INTEGRITY TEST(0.1 OPH) <br /> 0 7.SELF MONITORING SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): <br /> GRAVITY FLOW 07. SELF MONITORING <br /> 0 9.BIENNIAL INTEGRITY TEST(0.1 kPH) GRAVITY FLOW(Chock all that appy)_ <br /> ❑ <br /> S. DAILY VISUAL MONITORING <br /> ❑9. BIENNIAL INTEGRITY TEST(0.1(PH) <br /> SECONDARILY CONTAINED PIPING SECONDARILY CONTAINED PIPING <br /> PRESSURIZED PIPING(Chock"tht appy) PRESSURIZED PIPING(Check ell that appy): <br /> 10. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL 10. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL <br /> ALARMS AND(Cheek aa) ALARMS AND(Chale wee) <br /> ❑a AUTO POMP SHUT OFF WHEN A LEAK OCCURS 0 a AUTO PUMP SHUT OFF WHEN A LEAK OCCURS <br /> ❑b. AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM 0 b AUTO POMP SHOT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM <br /> DISCONNECTION DISCONNECTION <br /> Oe. NO AUTO PUMP SHUF OFF Oc NOAUTOPUMPSHUTOFF <br /> 0 11. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)WITH FLOW SHUT <br /> OFF OR RESTRICTION 0 11. AUTOMATIC LEAK DETECTOR <br /> 0 12. ANNUAL INTEGRITY TEST(0.1 GEED ❑12. ANNUAL INTEGRITY TEST(0.1 GPH) <br /> SUCTION/GRAVITY SYSTEM SUCTION/GRAVITY SYSTEM <br /> 0 13. CONTINUOUS SOW SENSOR+AUDIBLE AND VISUAL ALARMS 0 13. CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS <br /> EMERGENCY GENERATORS ONLY(Chale all that appy) EMERGENCY GENERATORS ONLY(Cheek all thm appy) <br /> 0 14. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF• [314. CONTINUOUS SUMP SENSOR WITHOVf AUTO POMP SHUT OFF` <br /> AUDIBLE AND VISUAL ALARMS AUDIBLE AND VISUAL ALARMS <br /> 1115 AUTOMATIC LINE LEAK DETECTOR(3.0 GPHTEST)WITHOUT FLOW 0 15 AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST <br /> SHUT OFF OR RESTRICTION ( ) <br /> [116.ANNUAL INTEGRITY TEST(0.1 GPH) 0 16.ANNUAL INTEGRITY TEST(0.1 GPH) <br /> [117. DAILY VISUAL CHECK 0 17. DAILY VISUAL CHECK <br /> VIIL DISPENSER CONTAINMENT <br /> DISPENSERCONTAINNIENT 0 1.FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE 0 4.DAILY VISUAL CHECK <br /> DATEINSTALLED a6e 02.CONTINUOUS DISPENSERPAN SENSOR+AUDIBLE AND VISUAL ALARMS ®5.TRENCH LINER/MONITORING <br /> [13.CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR 0 6.NONE 4e� <br /> DISPENSER+AUDIBLE AND VISUAL ALARMS <br /> DL OWNER/OPERATOR SIGNATURE <br /> real*flim da mTmwatlon provided hem a true and amuime to the batofnry knowledge. <br /> S OF ONQN0t/IPERA1.DR DATE 4M <br /> /for Diane Leri IV23/02 <br /> AME OF OWNER/OPERATOR(prim) TITLE OF OWNER/OPERATOR 472 <br /> Chevron Products Com / ,'n^t S W I Retail ESH Specialist <br /> Penne NumM(Fm kralux oty) 473 Penn¢Appmved(For mal uae only) Permit Fapvtion lMte(Fm local ux <br /> oNy) 475 <br />