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I PIED PROGRAM CONSOLIDATED FOR t - �� <br /> TANK <br /> UNDERGROUND STORAGE TANKS - TANK PAGE 2 <br /> Vt.PIPING CONSTRUCTION(Check all that appy) Page _ of <br /> UNDERGROUND PIPING ABOVEGROUND PIPING <br /> SYSTEM TYPE ®1.PRESSURE Cl 2.SUCTION 13.GRAVITY 458 D 1.PRESSURE D 2. SUCTION 13.GRAVITY 459 <br /> CONSTRUCTION/ 0 1.SINGLE WALL C 3.UNED TRENCH D 99.OTHER 460 01.SINGLE WALL 0 95.UNKNOWN 462 <br /> MANUFACTURER 0 2.DOUBLE WALL C 95.UNKNOWN C 2.DOUBLE WALL C 99.OTHER <br /> MANUFACTURER TelefleX 461 MANUFACTURER 463 <br /> ❑1.BARE STEEL D 6.FRP COMPATIBLE wN00?6 METHANOL 01.BARE STEEL 0 6.FRP COMPATIBLE WADD%METHANOL <br /> 0 2.STAINLESS STEEL 17.GALVANIZED STEEL C UKNOWN 0 2. STAINLESS STEEL 0 7.GALVANIZED STEEL <br /> 13.PLASTIC COMPATIBLE W/CONTENTS D99. OTHER 13. PLASTIC COMPATIBLE WI CONTENTS D 8.FLEXIBLE(HOPE) C99. OTHER <br /> 0 4.FIBERGLASS C 8.FLEXIBLE(HDPE) [14. FIBERGLASS 19.CATHODIC PROTECTION <br /> D 5.STEEL W/COATING 0 9.CATHODIC PROTECTION 464 D 5. STEEL WICOATING 0 95.UNKNOWN 465 <br /> a t, VII.PIPING LEAK DETECTION.(Check an that appy)(A descdpdon of the monitoring program shall be submitlea to the locat agency.) <br /> UNDERGROUND PIPING ABOVEGROUND PIPING <br /> SINGLE WALL PIPING 466 SINGLE WALL PIPING 467 <br /> PRESSURIZED PIPING(Check au matapply) PRESSURIZED PIPING(Check all that apply): <br /> 01. ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP SHUT OFF FOR C1, ELECTRONIC UNE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP SHUT OFF FOR <br /> LEAK,SYSTEM FAILURE,AND SYSTEM DISCONNECTION+AUDIBLE AND VISUAL LEAK,SYSTEM FAILURE,AND SYSTEM DISCONNECTION-AUDIBLE AND VISUAL <br /> ALARMS. ALARMS. <br /> 12. MONTHLY 0.2 GPH TEST 0 2. MONTHLY 0.2 GPH TEST <br /> 03. ANNUAL INTEGRITY TEST(0.1GPH) 13. ANNUAL INTEGRITY TEST(O.1GPH) <br /> 14. DAILY VISUAL CHECK <br /> CONVENTIONAL SUCTION SYSTEMS CONVENTIONAL SUCTION SYSTEMS(Check at that apply) <br /> 05. DAILY VISUAL MONITORING OF PUMPING SYSTEM,TRIENNIAL PIPING INTEGRITY 05. DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM <br /> TEST(0.1 GPH) <br /> SAFE SUCTION SYSTEMS(NO VALUES IN BELOW GROUNDPIPING): 06, TRIENNIAL INTEGRITY TEST(0.1 GPH) <br /> 07. SELF MONITORING SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): <br /> GRAVITY FLOW [17. SELF MONITORING <br /> 09. BIENNIAL INTEGRITY TEST(0.1 GPH) GRAVITY FLOW(Chi all mat apply): <br /> [18. DAILY VISUAL MONITORING <br /> [19, BIENNIAL INTEGRITY TEST(0.1 GPH) <br /> SECONDARILY CONTAINED PIPING SECONDARILY CONTAINED PIPING <br /> PRESSURIZED PIPING(Check all that apply): PRESSURIZED PIPING(Check all that apply): <br /> 10, CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL ALARMS AND 10, CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL ALARMS AND <br /> (Check one) (Check one) <br /> 1 a AUTO PUMP SHUT OFF WHEN A LEAK OCCURS 02 AUTO PUMP SHUT OFF WHEN A LEAK OCCURS <br /> 1 b. AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM Ob AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM <br /> DISCONNECTION DISCONNECTION <br /> I NOAUTO PUMP SHUT OFF Oc NO AUTO PUMP SHUT OFF <br /> ®11. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)WITH FLOW SHUTOFF OR 111 AUTOMATIC LEAK DETECTOR <br /> RESTRICTION <br /> 012. ANNUAL INTEGRITY TEST(0.1 GPH) [112. ANNUAL INTEGRITY TEST(0.1 GPH) <br /> SUCTION/GRAVITY SYSTEM SUCTION/GRAVITY SYSTEM <br /> 013. CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS [113. CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS <br /> EMERGENCY GENERATORS ONLY(Check all that appy) EMERGENCY GENERATORS ONLY(Check all Mat appy) <br /> 014. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF AUDIBLE AND 114. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF+AUDIBLE AND <br /> VISUALAIARMS VISUALALARMS <br /> 0 15, AUTOMATIC UNE LEAK DETECTOR(3.0 GPH TEST)WITHOU FLOW SHUT OFF OR 015. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST) <br /> RESTRICTION <br /> 116, ANNUAL INTEGRITY TEST(0.1 GPH) 0 16, ANNUAL INTEGRITY TEST(0.1 GPH) <br /> 117. DAILY VISUAL CHECK D17. DAILY VISUAL CHECK <br /> - VIM DISPENSER CONTAINMENT <br /> DISPENSER ®1 FLOAT MECHANISM THAT SHUTS OFF SHEARVALVE 04.DAILY VISUAL CHECK <br /> CONTAINMENT <br /> DATE INSTALLED 466 E12 CONTINUOUS DISPENSER PAN SENSOR•AUDIBLE AND VISUAL ALARMS 0 5.TRENCH LINER/MONITORING <br /> 1999 D 3 CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR DISPENSER+ 16.NONE 455 <br /> AUDIBLE AND VISUAL ALARMS <br /> IX.OWNERIOPERATOR SIGNATURE <br /> I ceI that the mformatm omded herein is true le accurate to the best of my knowledge. <br /> SIGNATURE O E OPERATOR DATE ^ 47g <br /> NAME OF OWNER/OPRATOR(print) TITLE OF OWNER/OPERATOR 472 <br /> Robert E. Hoover Retail Environmental Administrator <br /> Permt Number(For local use only) 473 Permit Approved(For local use only) Permit Expiration Date(For local use only) <br /> 475 <br /> UPCF (1/99 revised) Formerly SWRCB Form B <br />