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�IFIED PROGRAM CONSOLIDATED F(140I TANKS UNDERGROUND STORAGE TANKS - TANK PAGE 2 VI.PIPING CONSTRUCTION(Check all that apply) Page 33 or 43 UNDERGROUND PIPING ABOVEGROUND PIPING SYSTEM TYPE ❑ 1.PRESSURE ❑2.SUCTION ❑ 3.GRAVITY 458 ❑ L PRESSURE ❑ 2.SUCTION [:13.GRAVITY 459 CONSTRUCTION ❑ 1.SINGLE WALL ❑ 3.LINED TRENCH ❑ 99.OTHER 469 ❑ 1.SINGLE WALL ❑ 95.UNKNOWN m2 ❑ 2.DOUBLE WALL ❑95.UNKNOWN ❑ 2.DOUBLE WALL ❑ 99.OTHER 463 MANUFACTURER MANUFACTURER ❑ 1.BARE STEEL ❑ 6.FRP COMPATIBLE w/100%METHANOL ❑ 1.BARE STEEL ❑ 6.FRP COMPATIBLE w/100%METHANOL ❑2.STAINLESS STEE ❑ 7.GALVANIZED STEEL ❑ 2.STAINLESS STEE ❑ 7.GALVANIZED STEEL ❑PLASTIC COMPATIBLE W/CONTENTS ❑ 95.UNKNOWN ❑PLASTIC COMPATIBLE W/CONTENTS ❑ 95.UNKNOWN [14.FIBERGLASS ❑ 8.FLEXIBLE(HDPE) [199.OTHER ❑ 4.FIBERGLASS ❑ 8.FLEXIBLE(HDPE) ❑ 99.OTHER ❑ 5.STEEL W/COATING ❑ 9.CATHODIC PROTECTION 464 ❑ 5.STEEL W/COATING ❑ 9.CATHODIC PROTECTION 465 VII.PIPING LEAK DETECTION(Check all that appy)(A description of me tmnitoring program shall be subnhncd to the local agency.) UNDERGROUND PIPING ABOVEGROUND PIPING SINGLE WALL PIPING 466 SINGLE WALL PIPING 467 PRESSURIZED PIPING(Check all that appy): PRESSURIZED PIPING(Check all that appy): ❑ 1.ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WI'I'f AUTO PUMP ❑ 1.ELECTRONIC LINE LEAK DETECTOR 3.0 GPH 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 GPH TEST ❑ 2.MONTHLY 0.2 GPH TEST [13.ANNUAL INTEGRITY TEST(0.1 GPH) ❑ 3.ANNUAL INTEGRITY TEST(0.1 GPH) ❑ 4.DAILY VISUAL CHECK CONVENTIONAL SUCTION SYSTEMS CONVENTIONAL SUCTION SYSTEMS(Cl=k all that app1Y) ❑ 5.DAILY VISUAL MONITORING OF PUMPING SYSTEM+TRIENNIEAL ❑ 5.DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM PIPING INTEGRITY TEST(0.1 GPH) ❑ 6.TRIENNIAL.INTEGRITY TEST(0.1 GPH) SAFE SUCTION SYSTEMS(NO VALUES IN BELOW GROUNDPIPING): SAFE SUCTION SYSTEMS(NO VALUES IN BELOW GROUNDPIPING): ❑ 7.SELF MONITORING ❑ 7.SELF MONITORING GRAVITY FLOW [19.BIENNIAL INTEGRITY TEST(0.1)GPH GRAVITY FLOW(Check a0 that appy). ❑ 8.DAILY VISUAL MONITORING ❑ 9.BIENNIAL INTEGRITY TEST(0.1)GPH SECONDARILY CONTAINED PIPING SECONDARILY CONTAINED PIPING PRESSURIZED PIPING(Check all that apply): PRESSURIZED PIPING(Check all thus appNY 10.CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL 10.CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL ALARMS AND(CheWt.) ALARMS AND(Check on) ❑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 ❑b.AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM DISCONNECTION SYSTEM DISCONNECTION ❑ c. NO AUTO PUMP SHUT OFF ❑ c. NO AUTO PUMP SHUT OFF ❑ 11.AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)WIT ❑ 11,AUTOMATIC LEAK DETECTOR FLOW SHUT OFF OR RESTRICTION ❑ 12.ANNUAL INTEGRITY TEST(0.1 GPH) ❑ 12.ANNUAL INTEGRITY TEST(0.1 GPH) SUCTION/GRAVrrY SYSTEM SUCTION/GRAVITY SYSTEM ❑ 13.CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS ❑ 13.CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS EMERGENCY GENERATORS ONLY((1heek all thaz appy) EMERGENCY GENERATORS ONLY(Check all that appy) ❑ 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 ❑ 15.AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)WITHOUT FLOW ❑ 15.AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)WITHOUT FLOW SHUT OFF OR RESTRICTION SHUT OFF OR RESTRICTION ❑ 16.ANNUAL INTEGRITY TEST(0.1 GPH) ❑ 16.ANNUAL INTEGRITY TEST(0.1 GPH) ❑ 17.DAILY VISUAL CHECK ❑ 17.DAILY VISUAL CHECK VIII.DISPENSER CONTAINMENT DISPENSER CONTAINMENT ❑ 1.FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE ❑ 4.DAILY VISUAL CHECK DATE INSTALLED 468 ❑ 2.CONTINUOUS DISPENSER PAN SENSOR+AUDIBLE AND VISUAL ALARMS ❑ 5.TRENCH LINER/MONITORING ❑ 3.CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR ❑ 6.NONE DISPENSER+AUDIBLE AND VISUAL ALARMS 469 IX.OWNER/OPERATOR SIGNATURE I certify that the mfommtion rovkleci herein a true atW accurate to the best or knowlecie. SIGNATURE OF OWNER/OPERATOR DATE 470 NAME OF OWNER/OPERATOR(print) TITLE OF OWNER/OPERATOR 471 472 Pcrnit NuMier(For local use only) 473 Permit Approved(For local use only) 474 Pemut Expiration Date(For local use only) 475 EE0000817 12/31/199 UPCF(12/99 revised)