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IFIED PROGRAM CONSOLIDATED FORM 7rY4 s O 7 TANKS UNDERGROUND STORAGE TANKS -TANK PAGE 2 -.VI.PIPING CONSTRUCTION(Checked Metappy) - UNDERGROUND PIPING ABOVEGROUND PIPING SYSTEM TYPE ❑ 1 PRESSURE Id 2.SUCTION ❑ 3. GRAVITY ❑ 1. PRESSURE ❑ 2.SUCTION ❑ 3. GRAVITY CONSTRUCTION/ ❑ 1.SINGLE WALL ❑I�3. LINEOTRENCH ❑a9. OTHER ❑ 1. SINGLE WALL ❑95. UNKNOWNMANUFACTURER ❑ 2. DOUBLE WALL Ra5. UNKNOWN ❑ 2, DOUBLE WALL ❑99. OTHER MANUFACTURER MANUFACTURER ❑ 1.BARESTEEL ❑ e. FRP COMPATIBLE WI 1M%METHANOL ❑ 1, BARE STEEL ❑ 8. FRPO0MPATIBLEW/1IX%ME1`MANOL MATERIALSAND ❑ 2. STAINLESSSTEEL ❑ T. GALVANIZEDSTEEL CORROSION 112. STAINLESS STEEL ❑ ]. GALVANIZED STEEL PROTECTION ❑ 3. PLASTICCOMPATIBLEWITHCONTENTS Sk95. UNKNOWN ❑ 3. PLASTIC COMPATIBLE WTH CONTENTS ❑ 8. FLEXIBLE(HOPE) ❑99. OTHER ❑ 4. FIBERGLASS ❑ 8. FLEXIBLE(HDPE) 1199. OTHER ❑ 4. FIBERGLASS �1 139. CATHODIC PROTECTION ❑ 5. STEELWICOATING ❑ S. CATHODIC PROTECTION El 5, STEELW/COATING 6h95. UNKNOWN VII.PIPING LEAK DETECTION(Chock all that appy) SINGLE WALLPIPING UNDERGROUND PIPING ABOVEGROUND PIPING SINGLE WALL PIPING PRESSURIZED PIPING(Check adthat epplN: PRESSURIZED PIPING(Check eI that appy): ❑ 1. ELECTRONIC LINE LEAK DETECTOR 3.0 GPM TEST WITH AUTO PUMP SHUT OFF FOR ❑ 1. ELECTRONIC LINE LEAK DETECTOR 3.0 GPM TEST WITH AUTO PUMP SHUT OFF FOR LEAK, LEAK,SYSTEM FAILURE,AND SYSTEM DISCONNECTION+AUDIBLE AND VISUAL SYSTEM FAILURE,AND SYSTEM DISCONNECTION;-AUDIBLE AND VISUAL ALARMS ALARMS ❑ 112.MONTHLY 02 GPM TEST 2.MONTHLY 0.2 GPM TEST 3.ANNUAL INTEGRITY TEST(DA GPM) ❑ 3.ANNUAL INTEGRITY TEST(0.1 GPM) ❑ ❑ 4. DAILY VISUAL CHECK CONVENTIONAL SUCTION SYSTEMS: CONVENTIONAL SUCTION SYSTEMS(Check all Mal e,M: ❑ 5. DAILY VISUAL MONITORING OF PUMPING SYSTEM+TRIENNIAL PIPING INTEGRITY ❑ S. DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM TEST(0.1 GPM) ❑ B. TRIENNIAL INTEGRITY MST(O.1 GPM) SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): ❑ ]. SELFMONITORING - ❑ ]. SELF MONITORING - GRAVITY FLOW. - GRAVITY FLOW(Chookadlhat eppyJ: ❑ S. BIENNIAL INTEGRITY TEST(0.11 GPM) ❑ 8. DAILY VISUAL MONITORING ❑ 9. BIENNIAL INTEGRITY TEST(0.1 GPM) SECONDARILY CONTAINED PIPING NDARILY CONTAINED PIPING PRESSURIZED PIPING(Check all that apply): SECONDARILY PRESSURIZED PIPING(Check W that SECO 10. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL ALARMS AND (Chea one) 10.CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL ALARMS AND(ohea ane) ❑ a. AUTO PUMP SHUT OFF WHEN A LEAK OCCURS ❑ a.AUTO PUMP SHAT OFF MEN A LEAK OCCURS ❑ E AUTO PUMP T OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM DISCONNECTION ❑ b.AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM DISCONNECTION ❑ c NO AUTO PUMP SHUT OFF ❑ o. NO AUTO PUMP SHUT OFF ❑ 11. AUTOMATIC LINE LEAK DETECTOR(3.0 GPM TEST)WITH FLOW SHUT OFF OR ❑ 11, AUTOMATIC LEAK DETECTOR RESTRICTION ❑ 12.ANNUAL INTEGRITY TEST(0.1 GPM) ❑ 12.ANNUAL INTEGRIWTEST(DI GPM) SUCTIOWGRAVITY SYSTEM: SUCTIOWGRAVITY SYSTEM: ❑ 13. CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS ❑ 13.CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS EMERGENCY GENERATORS ONLY(Clove ed Mat eppW EMERGENCY GENERATORS ONLY(Check ad Mat appy) ❑ 14.CONTINUOUS SUMP SENSOR WITHOUT ALTO PUMP SHUT OFF+AUDIBLE AND VISUALALARMS 1114. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF+AUDIBLE AND VISUAL ALARMS ❑ 15.AUTOMATIC LINE LEAK DETECTOR(3.0 GPM TEST)WITHOUT FLOW SHUT OFF OR ❑ 15. AUTOMATIC LINE LEAK DETECTOR(3.0 GPM TEST) RESTRICTION ❑ 16.ANNUAL INTEGRITY TEST(0.1 GPM) ❑ 16. ANNUAL INTEGRITY TEST(0.1 GPM) ❑ 17. DAILY VISUAL CHECK ❑ 17. DAILY VISUAL CHECK VHI.DISPENSER CONTAINMENT DISPENSER CONTAINMENT ❑ 1. FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE ❑ 4. DAILY VISUAL CHECK DATE INSTALLED ❑ 2. CONTINUOUS DISPENSER PAN SENSOR+AUDIBLE AND VISUAL ALARMS ❑pGT 5. TRENCH LINER/MONITORING ❑ 3. CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR DISPENSER+AUDIBLE AND VISUAL ALARMS ALE. NONE IX.OWNER/OPERATOR SIGNATURE I unrcy t Me inl ation Pao rem is true an6 eavnte Ip 8w East of my Fnewle09e. SIGN R F PE - DATE 9 a NAME OF NER/OPERATOR(pdny , J TITLE OF ONWNE IJEPER�T9R Permit Nember(Fort l ws pray) Permir Appmvee(Fwha:al um wr/y) Permit ExpirstIon Del,(Forlocal uae enW CUPAFORM(4/99) Formerly SWRCB Form B