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untrr�✓ rnvu nrtn uvrva✓u✓Mr cu rvnm 1 <br /> ? TANK <br /> UNDER OUND STORAGE TANKS -•NK PAGE 2 n <br /> 1 VI.PIPING CONSTRUCTION(Check all that apply) Page_ of <br /> UNDERGROUND PIPING ABOVEGROUND PIPING <br /> SYSTEM TYPE 0 1.PRESSURE 0 2.SUCTION 0 3.GRAVITY 458 0 L PRESSURE 0 2, SUCTION 0 3.GRAVITY 459 <br /> CONSTRUCTION/ 0 1.SINGLE WALL 0 3.LINED TRENCH 0 99.OTHER 460 0 1.SINGLE WALL 0 95.UNKNOWN 462 <br /> MANUFACTURER ®2.DOUBLE WALL 0 95.UNKNOWN 0 2.DOUBLE WALL 0 99.OTHER <br /> MANUFACTURER AO Smith 461 MANUFACTURER_ 483 <br /> 0 1.BARE STEEL 0 6.FRP COMPATIBLE w/t0o% METHANOL 01.BARE STEEL 0 6.FRP COMPATIBLE wi mEIHANOL <br /> 0 2.STAINLESS STEEL 0 7.GALVANIZED STEEL 0 UKNOWN [12. STAINLESS STEEL [17.GALVANIZED STEEL <br /> 03.PLASTIC COMPATIBLE W/CONTENTS 099. OTHER 03. PLASTIC COMPATIBLE W/CONTENTS 08.FLEXIBLE(HDPE) 099. OTHER <br /> 04.FIBERGLASS 08.FLEXIBLE(HOPE) 04. FIBERGLASS 09.CATHODIC PROTECTION <br /> 0 5.STEEL W/COATING 0 9.CATHODIC PROTECTION 464 0 5. STEEL W/COATING 0 95.UNKNOWN 465 <br /> VII.PIPING LEAK DETECTION(Check all that apply)(A description of the monitoring program shall be submitted to the local agency.) <br /> UNDERGROUND PIPING ABOVEGROUND PIPING <br /> SINGLE WALL PIPING 466 SINGLE WALL PIPING 467 <br /> PRESSURIZED PIPING(Checkali Matapply): PRESSURIZED PIPING(Check all that apply): <br /> 01. ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TESTS AUTO PUMP SHUTOFF FOR 01. ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TESTN} ITH AUTO PUMP SHUT OFF FOR <br /> LEAK,SYSTEM FAILURE,AND SYSTEM DISCONNECTION+AUDIBLE AND VISUAL LEAK,SYSTEM FAILURE,AND SYSTEM DISCONNECTION+AUDIBLE AND VISUAL <br /> ALARMS. ALARMS. <br /> 0 2. MONTHLY 0.2 GPH TEST 0 2. MONTHLY 0.2 GPH TEST <br /> 03. ANNUAL INTEGRITY TEST(0.1GPH) 03. ANNUAL INTEGRITY TEST(0.1GPH) <br /> 04. DAILY VISUAL CHECK <br /> CONVENTIONAL SUCTION SYSTEMS CONVENTIONAL SUCTION SYSTEMS(Checkallthatapply) <br /> 05. DAILY VISUAL MONITORING OF PUMPING SYSTEM+TRIENNIAL PIPING INTEGRITY 05. DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM <br /> TEST(0.1 GPH) <br /> SAFE SUCTION SYSTEMS(NO VALUES IN BELOW GROUNDPIPING): [16. TRIENNIAL INTEGRITY TEST(0.1 GPH) <br /> 07. SELFMONITORING SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): <br /> GRAVITY FLOW 07. SELF MONITORING <br /> 09. BIENNIAL INTEGRITY TEST(0.1 GPH) GRAVITY FLOW(Check all that appfyl: <br /> 08. DAILY VISUAL MONITORING <br /> 09. BIENNIAL INTEGRITY TEST(0.1 GPH) <br /> SECONDARILY CONTAINED PIPING SECONDARILY CONTAINED PIPING <br /> PRESSURIZED PIPING(Check all that apply): 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 <br /> (Check ane) (Checkane) <br /> 0a. AUTO PUMP SHUT OFF WHEN A LEAK OCCURS 0a AUTO PUMP SHUT OFF WHEN A LEAK OCCURS <br /> ®b. AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM 0 b AUTO PUMP SHUTOFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM <br /> DISCONNECTION DISCONNECTION <br /> Oc. NOAUTOPUMPSHUTOFF Oc NO AUTO PUMP SHUT OFF <br /> 011. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)WITH FLOW SHUTOFF OR O 11, AUTOMATIC LEAK DETECTOR <br /> RESTRICTION <br /> 012. ANNUAL INTEGRITY TEST(0.1 GPH) 012. ANNUAL INTEGRITY TEST(0.1 GPH) <br /> SUCTION/GRAVITY SYSTEM SUCTIONIGRAVITY SYSTEM <br /> 013, CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS 013. CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS <br /> EMERGENCY GENERATORS ONLY(Check all that apply) EMERGENCY GENERATORS ONLY(Check all that apply) <br /> 014. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF+AUDIBLE AND 014. CONTINUOUS SUMP SENSOR WITHOU AUTO PUMP SHUT OFF+AUDIBLE AND <br /> VISUALALARMS VISUALALARMS <br /> [115. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)WITHOUT FLOW SHUTOFFOR 0 15. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST) <br /> RESTRICTION <br /> 016. ANNUAL INTEGRITY TEST(0.1 GPH) 016. ANNUAL INTEGRITY TEST(0.1 GPH) <br /> 017. DAILY VISUAL CHECK 017, DAILY VISUAL CHECK <br /> VIII.DISPENSER CONTAINMENT <br /> DISPENSER 01. FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE 04.DAILY VISUAL CHECK <br /> CONTAINMENT <br /> DATEINSTALLED 468 02. CONTINUOUS DISPENSER PAN SENSOR+AUDIBLE AND VISUAL ALARMS 05.TRENCH LINER/MONITORING <br /> 1998 D3. CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR DISPENSER+ [16.NONE 469 <br /> AUDIBLE AND VISUAL ALARMS <br /> IX.OWNER/OPERATOR SIGNATURE ,. ...w.. r, ...,"✓nvv °Lr vn @ <br /> I certify that the information provided herein is true an accurate to the best of my knowledge. <br /> SIGNATURE OF OWNER/OPERATO DATE O 470 <br /> NAME OF OWNER/OPRATOR(print) U TITLE OF OVINERIOPERATOR 472 <br /> Sandy Huff Operations & Environmental Specialist <br /> Permit Number(For local use only) 473 Permit Approved(For local use only) Permit Expiration Date(For local use only) <br /> 475 <br /> UPCF(1/99 revised) Formerly SWRCB Form B <br />