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♦.PIFIED PROGRAM CONSOLIDATED FO,.A TANK UNDERGROUND STORAGE TANKS TANK PAGE 2 VI.PIPING CONSTRUCTION(Chat all that a ly) Pale,4 or 6 UNDERGROUND PIPING ABOVEGROUND PIPING SYSTEM TYPE ®1.PRESSURE ❑2.SUCTION ❑3.GRAVITY 458 1 ❑1.PRESSURE ❑2. SUCTION ❑3.GRAVITY 459 coNBTRucrloN [11.SINGLE WALL [13.LINED TRENCH [199.OTHER 460 ❑1.SINGLE WALL [195.UNKNOWN 462 MANUFACTURER N 2.DOUBLE WALL ❑95.UNKNOWN ❑2.DOUBLE WALL ❑99.OTHER MANUFACTURER AO Snuth 461 MANUFACTURER_ 463 ❑1.BARE STEEL ❑6.FRP COMPATIBLE W/loose METHANOL 0 L BARE STEEL ❑6.FRP COMPATIBLE W/100%D TMNOL ❑2.STAINLESS STEEL ❑7.GALVANIZED STEEL ❑Unknown ❑2. STAINLESS STEEL [17.GALVANIZED STEEL ❑3.PLASTIC COMPATIBLE W/CONTENTS ❑99. Other ❑3. PLASTIC COMPATIBLE W/CONTENTS ❑8.FLEXIBLE(HDPE) ❑99. OTHER N 4.FIBERGLASS ❑8.FLEXIBLE(HDPE) ❑4. FIBERGLASS ❑9.CATHODIC PROTECTION El 5.STEEL W/COATING ❑9.CATHODIC PROTECTION 464 ❑5. STEEL W/COATING [195.UNKNOWN 465 VII.PIPING LEAK DETECTION(check all mat aPply> w amcription ofthe moadonne prolEarn.hall Ee sahmeted to the local eacy.) UNDERGROUND PIPING ABOVEGROUND PIPING SINGLE WALL PIPING 466 SINGLE WALL PIPING 467 PRESSURIZED PIPING(Check all tin apply@ PRESSURIZED PIPING(Chale all that apply): ❑1.ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP SHUT ❑ 1. ELECTRONIC LINE LEAK DETECTOR 3.0 GPH 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 GPH TEST ❑2. MONTHLY 0.2 GPH TEST ❑3.ANNUAL INTEGRITY TEST(O.IGPM ❑3.ANNUAL INTEGRITY TEST(O.IGPH) ❑4. DAILY VISUAL CHECK CONVENTIONAL SUCTION SYSTEMS CONVENTIONAL SUCTION SYSTEMS(Check all that apply) ❑5.DAILY VISUAL MONITORING OF PUMPING SYSTEM+TRIENNIAL PIPING 0 5. DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM INTEGRITY TEST(0.1 GPH) SAFE SUCTION SYSTEMS(NO VALUES IN BELOW GROUND PIPING): ❑6. TRIENNIAL INTEGRITY TEST(0.1 GPH) ❑7.SELF MONITORING SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): GRAVITY FLOW 07. SELF MONITORING [19.BIENNIAL INTEGRITY TEST(0.1 GPH) GRAVITY FLOW(Check all that apply): ❑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(Chock ail mat apply): 10. CONTINUOUS TURBINE SUMP SENSOR WITF AUDIBLE AND VISUAL 10. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL ALARMS AND(Chock nee) ALARMS AND(Chock one) N a. AUTO PUMP SHUT OFF WHEN A LEAK OCCURS ❑a AUTO PUMP SHUT OFF WHEN A LEAK OCCURS N b. AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM ❑b AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM DISCONNECTION DISCONNECTION [1c. NO AUTO PUMP SHUT OFF Oc NO AUTO PUMP SHUT OFF N 11. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)WITH FLOW SHUT 0 11 AUTOMATIC LEAK DETECTOR OFF OR RESTRICTION N 12. ANNUAL INTEGRITY TEST(0.1 GPH) ❑12. ANNUAL INTEGRITY TEST(0.1 GPH) SUCTION/GRAVITY SYSTEM SUCTION/GRAVITY SYSTEM ❑13. CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS [113. CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS EMERGENCY GENERATORS ONLY(cheek all that apply) EMERGENCY GENERATORS ONLY(Chock all tlut 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(3.0 GPH TEST)WITHOUT FLOW 015. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST) SHUT OFF OR RESTRICTION ❑16.ANNUAL INTEGRITY TEST(0.1 GPH) [116.ANNUAL INTEGRITY TEST(0.1 GPH) [117. DAILY VISUAL CHECK ❑17. DAILY VISUAL CHECK VIII.DISPENSER CONTAINMENT DISPENSER CONTAINMENT ❑1.FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE [:14.DAILY VISUAL CHECK DATE INSTALLED 468 N 2.CONTINUOUS DISPENSER PAN SENSOR+AUDIBLE AND VISUAL ALARMS ❑5.TRENCH LINER/MONITORING 7/11/91 N 3.CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR 0 6.NONE 469 DISPENSER+AUDIBLE AND VISUAL ALARMS IX.OWNER/OPERATOR SIGNATURE I certify mat the iafcmation rovidodlmreia'4uc andaccuratew the lat ofmyknowbdpe. SIGNATURE OF R R DATE 470 ID.P,LE9U 6/3/02 NAME OF OWN EROPRRATOINprino TITLE OF OWNEWOPERATOR 472 Chevron Products Co /D.R.LERI Retail ESH Specialist Pamir Number(For local me only) 473 Perron Approved(For local me only) Parma Expiation Date(Fa local me only) 475 UPCF(1/99 revised) 176 Formerly SWRCB Form B