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IED PROGRAM CONSOLIDATED FOR TANK UNDERGROUND STORAGE TANKS - TANK PAGE 2 Page _ of VI. PIPING CONSTRUCTION.(Check all that apply) UNDERGROUND PIPING ABOVEGROUND PIPING SYSTEM TYPE N 1.PRESSURE [12.SUCTION [13.GRAVITY 458 ❑1.PRESSURE ❑2. SUCTION ❑3.GRAVITY 459 ae CONSTRUCTION 1 ❑1.SINGLE WALL [13,LINED TRENCH [199.OTHER 46o ❑1.SINGLE WALL [:]95.UNKNOWN MANUFACTURER N 2.DOUBLE WALL ❑95.UNKNOWN ❑2.DOUBLE WALL [199.OTHER 463 MANUFACTURER Environ 461 MANUFACTURER_ ❑1.BARE STEEL ❑B.FRP COMPATIBLE WADO% METHANOL [11,BARE STEEL ❑6.FRP COMPATIBLE WIt11D%METHANOL [12.STAINLESS STEEL ❑7.GALVANIZED STEEL ❑UKNOWN ❑2. STAINLESS STEEL ❑7.GALVANIZED STEEL ❑3.PLASTIC COMPATIBLE WI CONTENTS 099. OTHER ❑3. PLASTIC COMPATIBLE WI CONTENTS ❑S.FLEXIBLE(HOPE) 099. OTHER N 4.FIBERGLASS N 8.FLEXIBLE(HDPE) [14. FIBERGLASS [19.CATHODIC PROTECTION [15.STEEL WICOATING [19,CATHODIC PROTECTION 464 [15. STEEL WICOATING ❑95.UNKNOWN 465 'VII.PIPING LEAK DETECTTUN(Check all thaLapply (A tleeaipeon M the monitoring program shABMsulonnitteal to the local OVEGROUND PIPING agency.) UNDERGROUND PIPING a67 SINGLE WALL PIPING 466 SINGLE WALL PIPING PRESSURIZED PIPING(Check as that apply): PRESSURIZED PIPING(Check an that apply): ❑1. ELECTRONIC UNE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP SHUT OFF FOR 01. ELECTRONIC UNE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP SHUT OFF FOR LEAK,SYSTEM FAILURE,AND SYSTEM DISCONNECTION+AUDIBLE AND VISUAL LEAK,SYSTEM FAILURE,AND SYSTEM DISCONNECTION+AUDIBLE AND VISUAL ALARMS. 02, MONTHLY 0.2 GPH TEST [12. MONTHLY 0.2 GPH TEST 03. ANNUAL INTEGRITY TEST(0.1GPH) L1 3. ANNUAL INTEGRITY TEST(0.1GPH) [14. DAILY VISUAL CHECK CONVENTIONAL SUCTION SYSTEMS CONVENTIONAL SUCTION SYSTEMS(Check WI Net apply) ❑5. DAILY VISUAL MONITORING OF PUMPING SYSTEM.TRIENNIAL PIPING INTEGRITY [15. DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM TEST(0.1 GPH) SAFE SUCTION SYSTEMS(NO VALUES IN BELOW GROUNDPIPING): [16. TRIENNIAL INTEGRITY TEST(0.1 GPH) 07. SELFMONITORING SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): GRAVITY FLOW ❑7. SELF MONITORING ❑9. BIENNIAL INTEGRITY TEST(0.1 GPH) GRAVITY FLOW(Check en that apply): ❑8. DAILY VISUAL MONITORING ❑9. 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 ALARMS AND 10. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL ALARMS AND CO (Checkmie) ❑a. AUTO PUMP SHUT OFF WHEN A LEAK OCCURS ❑a AUTO PUMP SHUT OFF WHEN A LEAK OCCURS Ob. AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM Ob AUTO DISCONNECTION PUMPSHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM DISCONNECTION pc. NO AUTO PUMP SHUT OFF Oc NO AUTO PUMP SHUT OFF N it. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)WITH FLOW SHUTOFF OR ❑11 AUTOMATIC LEAK DETECTOR RESTRICTION N Q. ANNUAL INTEGRITY TEST(0.1 GPH) 012. ANNUAL INTEGRITY TEST(0.1 GPH) SUCTION/GRAVITY SYSTEM SUCTIONIGRAVITY SYSTEM ❑13. CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS 013. CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS EMERGENCY GENERATORS ONLY(Check all that apply) EMERGENCY GENERATORS ONLY(Check all that apply) ❑14. CONTINUOUS SUMP SENSOR WITH UT AUTO PUMP SHUT OFF+AUDIBLE AND ❑14. V CONTINUOUS TINU USS MP SENSOR WITH T AUTO PUMP SHUT OFF+AUDIBLE AND VISUAL AU RMS [315. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)WITHOUT FLOW SHUT OFF OR [115, AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST) RESTRICTION 016. ANNUAL INTEGRITY TEST(0.1 GPH) ❑i6. ANNUALINTEGRITY TEST(0.1 GPH) 017. DAILY VISUAL CHECK 017. DAILY VISUAL CHECK `VIII.DISPENSER CONTAINMENT DISPENSER 01. FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE ❑4.DAILY VISUAL CHECK CONTAINMENT DATEINSTALLED 468 CONTINUOUS DISPENSER PAN SENSOR-AUDIBLE AND VISUAL ALARMS 05.TRENCH LINER/MONITORING 1995 CODIBNEOND US DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR DISPENSER+ [16.NONE 469 IX.OWNERIOPERATORSIGNATURE 1 certify that the Info ion pr ded her n is Iru curate to the best of my knoWledge. 470 SIGNATURE OF DATE NAME OF 0 RIOPRATOR(print) TITLE OF OWNEFUOPERATOR 472 Randy artin Gasoline & Environmental Com fiance Mana er Pemrt Number(For local use only) 473 Pemtlt Approved(For local use only) Permit Expiration Date(For local use only) 475 UPCF (1/99 revised) Formerly SWRCB Form B