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NIFIED PROGRAM CONSOLIDATED F M --- UNDERGROUND STORAGE TANKS - TANKTANKS PAGE 2 UNDERGROUND PIPING VI.PIPING CONSTRUCTION (Check eh that appl SYSTEM TYPE y) ❑ 1 PRESSURE ❑ 2. SUCTION ABOVEGROUND P CONSTRUCTION/ 111_ SINGLE WALL ❑ 3. LINED TRENCH ❑ 3 GRAVITY ❑ 1 PRESSURE IPING MANUFACTURER ❑ 2 DOUBLE WALL ❑99 OTHER ❑ 1. SINGLE WALL ❑ 2. SUCTION �95. UNKNOWN ❑ 3- GRAVITY MANUFACTURER ❑ 2. DOUBLE WALL ❑95. UNKNOWN ❑ 1 BARE STEELMANUFACTURER ❑99. OTHER MATERIALSAND ❑ 6. FRP COMPATIBLE W/100%METHANOL ❑ 1. BARE STEEL CORROSION ❑ 2. STAINLESS STEEL ❑ 7. GALVANIZED STEEL " PROTECTION ❑ 3. PLASTIC COMPATIBLE WITH CONTENTS ❑ 2. STAINLESS STEEL ❑ 8. FRP COMPATIBLE W/100%METHANOL ❑ 4. FIBERGLASS �95. UNKNOWN ❑ 3. PLASTIC COMPATIBLE WITH CONTENTS ❑ 7. GALVANIZED STEEL ❑ 8. FLEXIBLE(HDPE)✓✓✓ ❑99. OTHER, ❑ 4. FIBERGLASS ❑ 9_ FLEXIBLE(HDPE) ❑ 5 STEEL W/COATING ❑ 9. CATHODIC PROTECTION C15. STEEL W/COATING ❑ 9, CATHODIC PROTECTION ❑gg. OTHER SINGLE WALL PIPING UNDERGROUND PIPING VII.PIPING LEAK DETECTION(Check all that appy) ❑95. UNKNOWN PRESSURIZED PIPING(Check all that apply). ABOVEGROUND PIPING ❑ 1. ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP SHUT OFF FOR PRESSURIZED PIPING(Check all that apply).SINGLE WALL PIPING LEAK,SYSTEM FAILURE,AND SYSTEM DISCONNECTION+AUDIBLE AND VISUAL pp Y) ALARMS C11. ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP SHUT OFF FOR LEAK, ❑ 2. MONTHLY 0 2 GPM TEST SYSTEM FAILURE,AND SYSTEM DISCONNECTION;AUDIBLE AND VISUAL ALARMS ❑ 3 ANNUAL INTEGRITY TEST(0 1 GPH) ❑ 2 MONTHLY 0.2 GPH TEST ❑ 3 ANNUAL INTEGRITY TEST(0.1 GPH) CGNVENTKH:AL SUCTION SYSTEMS: ❑ 4. DAILY VISUAL CHECK NAL SUCTION SYSTEMS ❑ s pvLY VISUAL MONITORING OF PUMPING SYSTEM-TRIENNIAL PIPING INTEGRITY ❑NS.EDAIO (CheckY V SUAL MON TORWG OF PIPING AND PUMPING SYSTEM TEST(0 1 GPH) P SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPINGy ❑ 6 TRIENNIAL INTEGRITY TEST(0.1 GPM) ❑ 7 SELF MONITORING SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING)' GRAVITY FLOW ❑ 7. SELF MONITORING ❑ 9. BIENNIAL INTEGRITY TEST(0 1 GPH) GRAVITY FLOW(Check allthat a PR1Y)' ❑ 8. DAILY VISUAL MONITORING SECONDARILY CONTAINED PIPING 139 BIENNIAL INTEGRITY TEST(0.1 GPH) PRESSUP.IZED PIPING(Check all that apply). 10. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL ALARMS AND PRESSURIZED PIPING(Check all that SECONDARILY CONTAINED PIPING (Check one) PPIY) ❑ a AUTO PUMP SHUT OFF WHEN A LEAK OCCURS 10.CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL ALARMS AND(check one) ❑ b AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM ❑ a. AUTO PUMP SHUT OFF WHEN A LEAK OCCURS DISCONNECTION ❑ b. AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM DISCONNECTION ❑ c NO AUTO PUMP SHUT OFF 11 c. NO AUTO PUMP SHUTOFF ❑ 11 AUTOMATIC UNE LEAK DETECTOR(3.0 GPH TEST)WITH FLOW SHUT OFF OR RESTRICTION ❑ 11. AUTOMATIC LEAK DETECTOR ❑ 12. ANNUAL INTEGRITY TEST(0.1 GPM) ❑ 12. ANNUAL INTEGRITY TEST(0.1 GPH) SUCTIONIGRAVITY SYSTEM ❑ 13 CONTINUOUS SUMP SENSOR•AUDIBLE AND VISUAL ALARMS SUCTION/GRAVITY SYSTEM ❑ 13. CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS EMERGENCY GENERATORS ONLY(Check as that apply) ❑ 14 CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SMUT OFF+AUDIBLE AND ❑ EMERGENCY GENERATORS ONLY(Check all that apply) VISUAL ALARMS 14. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF•AUDIBLE AND VISUAL ❑ 15. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)WITHOUT FLOW SHUT OFF OR ALARMS RESTRICTION ❑ 15. AUTOMATIC LINE LEAK DETECTOR(3.0 GPM TEST) ❑ 16. ANNUAL INTEGRITY TEST(0.1 GPH) ❑ 17. DAILY VISUAL CHECK ❑ 16. ANNUAL INTEGRITY TEST(0.1 GPH) ❑ 17. DAILY VISUAL CHECK VIII.DISPENSER CONTAINMENT DISPENSER CONTAINMENT ❑ 1. FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE DATE INSTALLED ❑ 2. CONTINUOUS DISPENSER PAN SENSOR•AUDIBLE AND VISUAL ALARMS 1:1 5. TRENC ❑ 4. DAILY VISUAL CHECK --- ❑ 3. CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR DISPENSER+AUDIBLE AND VISUAL ALARMS ❑ 8. NONE H LINER/MONITORING I cerbfy Nat the infonnahon provided herein is true and accurate to the best of my knowleageX.OWNER/OPERATOR SIGNATURE SIGNATURE OF'OWNLWQPERATOR DATE NAME OF OWNER/OPERATOR(print) TITLE OF OWNER/OPERATOR Pennd Number(For local use on1yJ Permit Approved(For local use only) Permit Expiration Date(For local use only) JPAFORM(4/99) Formerly SWRCB Form B