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PNIFIED PROGRAM CONSOLIDATED FOR` TANKS UNDERGROUND STORAGE TANKS - TANK PAGE 2 A.PIPING CONSTRUCTION(Check a¢tAeleppy) UNDERGROUND PIPING ABOVEGROUND PIPING SYSTEM TYPE 1. PRESSURE ❑ 2. SUCTION ❑ 3. GRAVITY ❑ 1. PRESSURE ❑ 2. SUCTION ❑ 3. GRAVITY CONSTRUCTION/ ❑ 1. SINGLE WALL ❑ 3. LINEDTRENCH ❑99. OTHER ❑ 1. SINGLE WALL ❑95. UNKNOWN MANUFACTURER 2. DOUBLE WALL ❑95. UNKNOWN ❑ 2. DOUBLE WALL 1199. OTHER MANUFACTURER MANUFACTURER ❑ 1.BARE STEEL ❑ S. FRP COMPATIBLE W/10o%METHANOL ❑ 1. BARE STEEL ❑ 0. FRP COMPATIBLE W/100%METHANOL MATERIALSAND ❑ 2. STAINLESS STEEL ❑ 7. GALVANIZED STEEL ❑ 2. STAINLESS STEEL ❑ T. GALVANIZED STEEL CORROSION 13 `N 3. PROTECTION 3. PLASTIC COMPATIBLE WITH CONTENTS ❑95. UNKNOWN ❑ PLANTH COMPATIBLE TH CONTENTS 11 B. FLEXIBLE(HOPE) ❑N. OTHER ❑ 4. FIBERGLASS ❑ 0. FLEXIBLE(HDPE) 1199. OTHER ❑ T FIBERGLASS ❑ 9. CATHODIC PROTECTION ❑ S. STEEL W/COATING ❑ 9. CATHODIC PROTECTION ❑ 5. STEEL W/COATING ❑95. UNKNOWN VII.PIPING LEAK DETECTION(Check ad that appy) UNDERGROUND PIPING ABOVEGROUND PIPING SINGLE WALL PIPING SINGLE WALL PIPING PRESSURIZED PIPING(Check aB that appM' PRESSURIZED PIPING(Check aN that appy): ❑ 1. ELECTRONIC LINE LEAK DETECTOR 3.0 GPM TEST WITH AUTO PUMP SHUT OFF FOR ❑ I. ELECTRONIC LME LEAK DETECTOR 3.0 GPM TEST PATH AUTO PUMP SHUT OFF FOR LEAK, LEAK,SYSTEM FAILURE.AND SYSTEM DISCONNECTION+AUDIBLE AND VISUAL SYSTEM FAILURE,AND SYSTEM DISCONNECTION;AUDAUDIBLE AND VISUAL ALARMS ALARMS ❑ 2. MONTHLY 0.2 GPM TEST ❑ 2 MONTHLY 0.2 GPM TEST ❑ 3.ANNUAL INTEGRITY TEST(0.1 GPM) ❑ 3. ANNUAL VI UAL CHECK TEST(0.1 CPN) ❑ 4. DAILY VISUAL CHECK CONVENTIONAL SUCTION SYSTEMS'. CONVENTIONAL SUCTION SYSTEMS(Chxk all Met apply): ❑ 5. DAILY VISUAL MONITORING OF PUMPING SYSTEM+TRIENNIAL PIPING INTEGRITY ❑ S. DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM TEST(0.1 GPM) ❑ 0. TRIENNIAL INTEGRITY TEST(0.1 GPM) SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING) SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): ❑ T. SELF MONITORING ❑ 7. SELF MONITORING GRAVITY FLOW'. GRAVITY FLOW(Check all that appy)' ❑ 9. BIENNIAL INTEGRITY TEST(0.1 GPM) a ❑ 0. DAILY VISUAL MONITORING ❑ 9. BIENNIAL INTEGRITY TEST(0.1 GPM) SECONDARILY CONTAINED PIPING SECONDARILY CONTAINED PIPING PRESSURIZED PIPING(Check all that apply): PRESSURIZED PIPING(Check all that appy): 10. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL ALARMS AND 10.CONTINUOUS TURBINE SUMP SENSOR NTH AUDIBLE AND VISUAL ALARMS AND(cNeok one) (Check one) rl a. AUTO PUMP SHUT OFF WHEN A LEAK OCCURS ❑ is AUTO PUMP SHUT OFF WHEN A LEAK OCCURS �a AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM ❑ E, AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM DISCONNECTION DISCONNECTION ❑ c. NO AUTO PUMP SHUT OFF ❑ c. NO AUTO PUMP SMUT OFF 11. AUTOMATIC LINE LEAK DETECTOR(3.0 GPM TEST)NTH FLOW SHUT OFF OR ❑ 11. AUTOMATIC LEAK DETECTOR RESTRICTION ❑ 12. ANNUAL NTEGRITY TEST(0 1 GPM) ❑ 12.ANNUAL INTEGRITY TEST(0 t GPM) SUCTION/GRAVITY SYSTEM: SUCTION/GRAVITY SYSTEM: ❑ 13. CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS ❑ 13. CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS EMERGENCY GENERATORS ONLY(Check as that appy) EMERGENCY GENERATORS ONLY(Check all Mat appy) ❑ 14. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF+AUOIBLE AND ❑ 14.CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF+AUDIBLE AND VISUAL VISUAL ALARMS ALARMS ❑ 15. AUTOMATIC LINE LEAH DETECTOR(3.0 GPH TEST)WITHOUT FLOW SHUT OFF OR ❑ 15. AUTOMATIC LINE LEAK DETECTOR(3.0 GPM TEST) RESTRICTION ❑ 18. ANNUAL INTEGRITY TEST(0.1 GPM) ❑ 10. ANNUAL INTEGRITY TEST(0.1 GPM) ❑ 17. DAILYVISVALCHECK ❑ 17. DAILY VISUAL CHECK VIII.DISPENSER CONTAINMENT DISPENSER CONTAINMENT ❑ 1. FLOAT MECHANISM THAT SHUTS OFF SMEAR VALVE ❑ 4. DAILY VISUAL CHECK DATE INSTALLED ❑ 2. CONTINUOUS DISPENSER PAN SENSOR+AUDIBLE AND VISUAL ALARMS ❑ 5. TRENCH LINER/MONITORING ❑ 3. CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR DISPENSER+AUDIBLE AND VISUAL ALARMS B. NONE IX.OWNER/OPERATOR SIGNATURE 1 canary Mel Me Information provided Ismaili is Wa and ie=rate to Me East of my Mowled9e. SIGNATURE OF OMMERIOPERATOR DATE NAME OF OWNEWOPERATOR(hill TITLE OF OWNER/OPERATOR Permit Number/For local um Dory) Permit Apprnaed(Ferlocal use only) Permit Expirabon Date(Forlocal use amyl CUPAFORM(4/99) • • Formerly SWRCB Form B