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'IFIED PROGRAM CONSOLIDATED FO- I <br /> L. %ftw TANK <br /> UNDERGROUND STORAGE TANKS TANK PAGE 2 <br /> VI.PIPING CONSTRUCTION(cheek all that apply) Page 6 of 6 <br /> UNDERGROUND PIPING ABOVEGROUND PIPING <br /> SYSTEM TYPE 0 I.PRESSURE 0 2.SUCTION [13.GRAVITY 458 0 1.PRESSURE O 2. SUCTION [13.GRAVITY 459 <br /> CONSTRUCTION O 1.SINGLE WALL O 3.LINED TRENCH O 99.OTHER 460 0 L SINGLE WALL 0 95.UNKNOWN 462 <br /> h1ANUFACTURER 0 2.DOUBLE WALL 0 95.UNKNOWN 0 2.DOUBLE WALL O 99.OTHER <br /> MANUFACTURER AO Smith 461 MANUFACTURER_ 463 <br /> O 1.BARE STEEL [16.FRP COMPATIBLE w/loo. 1,1ETHANOL O 1.BARE STEEL 0 6.FRP COMPATIBLE W/loo.METHANOL <br /> O 2.STAINLESS STEEL O 7.GALVANIZED STEEL 0 Urdomy. 0 2. STAINLESS STEEL [17.GALVANIZED STEEL <br /> O 3.PLASTIC COMPATIBLE W/CONTENTS 0 99. Otter 0 3. PLASTIC COMPATIBLE W/CONTENTS 0 8.FLEXIBLE(HDPE) [199. OTHER <br /> 0 4.FIBERGLASS 0 8.FLEXIBLE(HDPE) O 4. FIBERGLASS 0 9.CATHODIC PROTECTION <br /> 0 S.STEEL W/COATING O 9.CATHODIC PROTECTION 464 0 5. STEEL W/COATING 0 95.UNKNOWN 465 <br /> VII.PIPING LEAK DETECTION(Cheek all that apply)(A description ofthe monitoring program shall be submined to the local y) <br /> UNDERGROUND PIPING ABOVEGROUND PIPING <br /> SINGLE WALL PIPING 466 SINGLE WALL PIPING 467 <br /> PRESSURIZED PIPING(Cheek a0 that apply): PRESSURIZED PIPING(Check all that apply): <br /> O 1.ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP SHUT 0 1. ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP <br /> OFF FOR LEAK,SYSTEM FAILURE,AND SYSTEM DISCONNECTION+ SHUT OFF FOR LEAK,SYSTEM FAILURE,AND SYSTEM DISCONNECTION+ <br /> AUDIBLE AND VISUAL ALARMS. AUDIBLE AND VISUAL ALARMS. <br /> O 2.MONTHLY 0.2 GPH TEST [12. MONTHLY 0.2 GPH TEST <br /> 0 3.ANNUAL INTEGRITY TEST(0.10PH) [13.ANNUAL INTEGRITY TEST(o.IGPH) <br /> O 4. DAILY VISUAL CHECK <br /> CONVENTIONAL SUCTION SYSTEMS CONVENTIONAL SUCTION SYSTEMS(Check all that apply) <br /> 0 5.DAILY VISUAL MONITORING OF PUMPING SYSTEM+TRIENNIAL PIPING 5. DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM <br /> INTEGRITY TEST(0.1 GPH) <br /> SAFE SUCTION SYSTEMS(NO VALUES IN BELOW GROUND PIPING): ❑6. TRIENNIAL INTEGRITY TEST(0.1 GPH) <br /> [17.SELF MONITORING SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): <br /> GRAVITY FLOW 0 7. SELF MONITORING <br /> [19.BIENNIAL INTEGRITY TEST(0.1 GPH) GRAVITY FLOW(Cheek all that apply): <br /> 0 8. DAILY VISUAL MONITORING <br /> O 9. BIENNIAL INTEGRITY TEST(0.1 GPH) <br /> SECONDARILY CONTAINED PIPING SECONDARILY CONTAINED PIPING <br /> PRESSURIZED PIPING(Check all that ryply): PRESSURIZED PIPING(Check all that apply) <br /> 10. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL 10. CONTINUOUS TURBINE SUMP SENSOR WIT AUDIBLE AND VISUAL <br /> ALARMS AND(Check ore) ALARMS AND(Check one) <br /> ®a. AUTO PUMP SHUT OFF WHEN A LEAK OCCURS O a AUTO PUMP SHUT OFF WHEN A LEAK OCCURS <br /> ®b. AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM ❑b AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM <br /> DISCONNECTION DISCONNECTION <br /> Oc. NO AUTO PUMP SHUT OFF Oc NO AUTO PUMP SHUT OFF <br /> 0 11. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)WITH FLOW SHUT 0 11 AUTOMATIC LEAK DETECTOR <br /> OFF OR RESTRICTION <br /> ®12. ANNUAL INTEGRITY TEST(0.1 GPH) 0 12. ANNUAL INTEGRITY TEST(0.1 GPH) <br /> SUCHOWGRAVITY SYSTEM SUCTION/GRAVITY SYSTEM <br /> [113. CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS O 13. CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS <br /> EMERGENCY GENERATORS ONLY(Cheek all that apply) EMERGENCY GENERATORS ONLY(Cheek all that apply) <br /> 0 14. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF" O 14. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF <br /> AUDIBLE AND VISUAL ALARMS AUDIBLE AND VISUAL ALARMS <br /> 0 15. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)WITHOUT FLOW 015. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST) <br /> SHUT OFF OR RESTRICTION <br /> 0 16.ANNUAL INTEGRITY TEST(0.1 GPH) 0 16.ANNUAL INTEGRITY TEST(0.1 GPH) <br /> 017. DAILY VISUAL CHECK 017. DAILY VISUAL CHECK <br /> VIII.DISPENSER CONTAINMENT <br /> DISPENSER CONTAINMENT O 1.FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE [14.DAILY VISUAL CHECK <br /> DATE INSTALLED 468 0 2.CONTINUOUS DISPENSER PAN SENSOR+AUDIBLE AND VISUAL ALARMS O 5.TRENCH LINER/MONITORING <br /> 7/11/91 0 3.CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR O 6.NONE 4(y9 <br /> DISPENSER+AUDIBLE AND VISUAL ALARMS <br /> M.OWNER/OPERATOR SIGNATURE <br /> I amity thatthe m i t e and accurate to the best of my knowledge. <br /> SIGNATURE Odj� ER DATE 470 <br /> fD.R,LAR( 6/3/02 <br /> NAME OF OWN O ries" TITLE OF OWNER/OPERATOR 472 <br /> Chevron Products Company/D.R. LERI Retail ESH Specialist <br /> Permit Number(For Beal use only) 473 Permit Approved(For local we only) Permit EVirtmon Date(For local we only) 475 <br /> UPCF(1/99 revised) 178 Formerly SWRCB Form B <br />