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• NwOIFIED PROGRAM CONSOLIDATED F;Iw TANK UNDERGROUND STORAGE TANKS TANK PAGE 2 VI.PIPING CONSTRUCTION(Check all that apply) Page 4 of 6 UNDERGROUND PIPING ABOVEGROUND PIPING SYSTEM TYPE ®I.PRESSURE ❑2.SUCTION ❑3.GRAVITY 458 ❑1.PRESSURE ❑2. SUCTION ❑3.GRAVITY 459 CONSTRUCTION ❑1.SINGLE WALL [13.LINED TRENCH [199.OTHER 4611 [11.SINGLE WALL [195.UNKNOWN 462 MANUFACTURER ®2.DOUBLE WALL ❑95.UNKNOWN ❑2.DOUBLE WALL ❑99.OTHER MANUFACTURER AO Smith 461 MANUFACTURER_ 463 ❑1.BARE STEEL ❑6.FRP COMPATIBLE what . METHANOL [11.BARE STEEL ❑6.FRP COMPATIBLE W/1008 METHANOL 2.STAINLESS STEEL [17.GALVANIZED STEEL ❑Unknown [12. STAINLESS STEEL ❑7.GALVANIZED STEEL ❑3.PLASTIC COMPATIBLE W/CONTENTS ❑99. Other ❑3. PLASTIC COMPATIBLE W/CONTENTS ❑8.FLEXIBLE(HDPE) ❑99. OTHER ®4.FIBERGLASS ❑8.FLEXIBLE(HDPE) ❑4. FIBERGLASS ❑9.CATHODIC PROTECTION [15.STEEL W/COATING ❑9.CATHODIC PROTECTION 464 ❑5. STEEL W/COATING 0 95.UNKNOWN 465 VII.PIPING LEAK DETECTION(Check all thatapply)(A deecriptican ofthe munkodng grog ran shall Ise submitted m the kxal enry) 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 SHUT [11. ELECTRONIC LME LEAK DETECTOR 3.0 GPM TEST WITH AUTO PUMP 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(OAGPH) ❑3.ANNUAL INTEGRITY TEST(OAGPM) ❑4. DAILY VISUAL CHECK CONVENTIONAL SUCTION SYSTEMS CONVENTIONAL SUCTION SYSTEMS(Cheek all that apply) ❑S.DAILY VISUAL MONITORING OF PUMPING SYSTEM+TRIENNIAL PIPING 0 S. DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM INTEGRITY TEST(0.1 GPM) SAFE SUCTION SYSTEMS(NO VALUES IN BELOW GROUND PIPING): [16. TRIENNIAL INTEGRITY TEST(0.1 GPH) [17.SELF MONITORING SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): GRAVITY FLOW ❑7. SELF MONITORING ❑9.BIENNIAL INTEGRITY TEST(0.1 GPM) GRAVITY FLOW(Cheek all that apply): ❑8. DAILY VISUAL MONITORING [19. BIENNIAL INTEGRITY TEST(0.1 GPM) SECONDARILY CONTAINED PIPING SECONDARILY CONTAINED PIPING PRESSURIZED PIPING(Check all that apply): PRESSURIZED PIPING(Check an mat apply): 10. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL 10. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL ALARMS AND(Check oa) 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 0 b AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM DISCONNECTION DISCONNECTION ®c. NO AUTO PUMP SHUT OFF 13c NO AUTO PUMP SHUT OFF ®11. AUTOMATIC LINE LEAK DETECTOR(3.0 GPM TEST)WITH FLOW SHUT 0 11. AUTOMATIC LEAK DETECTOR OFF OR RESTRICTION ®12. ANNUAL INTEGRITY TEST(0.1 GPM) [112. ANNUAL INTEGRITY TEST(0.1 GPM) SUCTION/GRAVITY SYSTEM SUCTION/GRAVITY SYSTEM [113. CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS ❑13. CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS EMERGENCY GENERATORS ONLY(Cheek all that apply) EMERGENCY GENERATORS ONLY(Cheek all that apply) [114. 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 ULO GPM TEST)WITHOUT FLOW [115. AUTOMATIC LINE LEAK DETECTOR(3.0 GPM TEST) SHUT OFF OR RESTRICTION ❑16.ANNUAL INTEGRITY TEST(0.1 GPM) [116.ANNUAL INTEGRITY TEST(0.1 GPM) [117. DAILY VISUAL CHECK ❑17. DAILY VISUAL CHECK VIII.DISPENSER CONTAINMENT DISPENSER CONTAINMENT ❑1.FLOAT MECHANISM THAT SHUTS OFF SMEAR VALVE ❑4.DAILY VISUAL CHECK DATE INSTALLED 468 [12.CONTINUOUS DISPENSER PAN SENSOR+AUDIBLE AND VISUAL ALARMS [15.TRENCH LINER/MONITORING 1991 ®3.CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR 0 6.NONE 469 DISPENSER+AUDIBLE AND VISUAL ALARMS IX.OWNER/OPERATOR SIGNATURE 1 certify tnat the inr nation provided herein is me and accaate eo the hat ofmy,krmwladae. SIGNATURE OF OWNER/OPERATOR DATE 470 C R,Canfwrd 06/26/2002 NAME OF OWNER/OPERATOR(Print) TITLE OF OWNER/OPERATOR 472 Chevron Products Co an /C.R. Canfield Retail ESH Specialist Pmnit Numbtr(For kwal use only) 473 Permit Approved(For local use only) Permit Expiration Date(For local use only) 475 UPCF(1/99 revised) 176 Formerly SWRCB Form B