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..1 TRT)PROGRAM C0NC0T.U1)ATRn FOIE TANKS UNDERGROUND STORAGE TANKS - TANK PAGE 2 Page_2 of_6_ VI.PIPING CONSTRUCTION(check am that apply) UNDERGROUND PIPING ABOVEGROUND PIPING SYSTEM TYPE ®1.PRESSURE [12.SUCTION O 3.GRAVITY 458. 0 1.PRESSURE O 2.SUCTION 0 3.GRAVITY 459. CONSTRUCTION/ 0 1.SINGLE WALL 0 3.LINED TRENCH 0 99.OTHER 460. ❑ L SINGLE WALL 0 95.UNKNOWN 4b2. MANUFACTURER ®2.DOUBLE WALL ❑95.UNKNOWN ❑2.DOUBLE WALL ❑99.OTHER MANUFACTURER ENVIRON 461. MANUFACTURER 463 0 L BARE STEEL 0 6.FRP COMPATIBLE W/100%METHANOL 0 1.BARE STEEL 0 6.FRP COMPATIBLE W1100%METHANOL 0 2.STAINLESS STEEL 0 7.GALVANIZED STEEL 0 2.STAINLESS STEEL 0 7.GALVANIZED STEEL 0 3.PLASTIC COMPATIBLE WITH CONTENTS E395.UNKNOWN 0 3.PLASTIC COMPATIBLE W/CONTENTS [18.FLEXIBLE(HDPE) [199.OTHER 0 4.FIBERGLASS O 8.FLEXIBLE(HDPE) [199.OTHER ❑4.FIBERGLASS 0 9.CATHODIC PROTECTION ❑5.STEEL W/COATING O 9.CATHODIC PROTECTION 464. 0 5.STEEL W/COATING ❑95.UNKNOWN 465. VII.PIPING LEAK DETECTION(Cheek an that apply)(A Oeurip[too of the monitoring program shall be submitted to the local agency.) UNDERGROUND PIPING ABOVEGROUND PIPING SINGLE WALL PIPING 466, SINGLE WALL PIPING 467. PRESSURIZED PIPING(Check all that apply): PRESSURIZED PIPING(Check all that apply): ❑1. ELECTRONIC LINE LEAK DETECTOR 3.0 GPM TEST WITH AUTO PUMP [11. ELECTRONIC LINE LEAK DETECTOR 3.0 GPM TEST WITH AUTO PUMP SHUT-OFF FOR LEAK,SYSTEM FAILURE,AND SYSTEM DISCONNECTION SHUT OFF FOR LEAK,SYSTEM FAILURE,AND SYSTEM DISCONNECTION +AUDIBLE AND VISUAL ALARMS. +AUDIBLE AND VISUAL ALARMS. ❑2. MONTHLY 0.2 GPM TEST ❑2. MONTHLY 0.2 GPM TEST ❑3. ANNUAL INTEGRITY TEST(0.1 GPM) [13. ANNUAL INTEGRITY TEST m.1 GPM) [14. DAILY VISUAL CHECK CONVENTIONAL SUCTION SYSTEMS CONVENTIONAL SUCTION SYSTEMS(Check all that apply) [15. DAILY VISUAL MONITORING OF PUMPING SYSTEM+TRIENNIAL PIPING [15. DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM INTEGRITY TEST(0.1 GPM) SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): [16. TRIENNIAL INTEGRITY TEST(0.1 GPM) [37. SELF MONITORING SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): GRAVITY FLOW O7. SELF MONITORING [19. BIENNIAL INTEGRITY TEST(0.1 GPM) GRAVITY FLOW(Check all that apply): [18. DAILY VISUAL MONITORING [39. BIENNIAL INTEGRITY TEST(0.1 GPM) 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 10. CONTINUOUS TURBINE SUMP SENSOR WIT AUDIBLE AND VISUAL ALARMS AND(Check one) ALARMS AND(Check one) ❑a. AUTO PUMP SHUT OFF WHEN A LEAK OCCURS ❑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 Oc. NOAUTO PUMP SHUTOFF Oc. NOAUTOPUMPSHUTOFF 0 11. AUTOMATIC LINE LEAK DETECTOR(3.0 GPM TEST)WITH FLOW SHUT OFF OR RESTRICTION ❑11. AUTOMATIC LEAK DETECTOR ❑12. ANNUAL INTEGRITY TEST(0.1 GPM) [112. ANNUAL INTEGRITY TEST m.I GPM) SUCTION/GRAVITY SYSTEM SUCTION/GRAVITY SYSTEM 013. CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS [113. 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 WITHOUT AUTO PUMP SHUT OFF ❑ 14.CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF AUDIBLE AND VISUAL ALARMS AUDIBLE AND VISUAL ALARMS 015. AUTOMATIC LINE LEAK DETECTOR (3.0 GPM TEST) WITHOUT FLOW ❑ SHUT OFF OR RESTRICTION I5. AUTOMATIC LINE LEAK DETECTOR(3.0 GPM TEST) [116. ANNUAL INTEGRITY TEST(0.1 GPM) [116. ANNUAL INTEGRITY TEST(0.1 GPM) 017. DAILY VISUAL CHECK ❑ 17. DAILY VISUAL CHECK VID.DISPENSER CONTAINMENT DISPENSER CONTAINMENT 468. ❑1. FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE ❑4. DAILY VISUAL CHECK 469. DATE INSTALLED 192. CONTINUOUS DISPENSER PAN SENSOR+AUDIBLE AND VISUAL ALARMS ❑5. TRENCHILINER MONITORING [13. CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR [16. NONE DISPENSER+AUDIBLE AND VISUAL ALARMS IDL OWNER/OPERATOR SIGNATURE I certify that the information provided herein is true and accurate to the best of my knowledge. SIGNATUR OO E DATE: /� I 470. U ZtJc./ Z NAME OF OW NER/OPERATOR(primt TITLE OF OW NER/OPERATOR: 473' /6t e w,, Permit Number(Agency use only) 473. 1 Permit Approved By(Agency use only) 474. 1 Permit Expiration Date(Agency use only) 475. UPCF hwfwm-b(1/99)-314 h/tpzt/www.unidocs.org Rev.021166