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FIED PROGRAM CONSOLIDATED FOF <br /> UNDERGROUND STORAGE TANKS - TANK PAGE 2�� TANK <br /> VI.PIPING CONSTRUCTION(Check an that apply) / j. !^ p,a/ Page_ of <br /> UNDERGROUND PIPING ABOVEGROUND PIPING <br /> SYSTEM TYPE ®1.PRESSURE D 2.SUCTION D 3.GRAVITY 458 C 1.PRESSURE D 2. SUCTION D 3.GRAVITY 459 <br /> CONSTRUCTION/ C 1.SINGLE WALL C 3.DINED TRENCH D 99.OTHER 450 C 1.SINGLE WALL C 95.UNKNOWN 462 <br /> MANUFACTURER ®2.DOUBLE WALL D 95.UNKNOWN C 2.DOUBLE WALL C 99.OTHER <br /> MANUFACTURER TelefleX 461 MANUFACTURER_ 463 <br /> C 1.BARE STEEL D 6.FRP COMPATIBLE w/100% METHANOL C 1.BARE STEEL [16.FRP COMPATIBLE W/100%METHANOL <br /> C 2.STAINLESS STEEL D 7.GALVANIZED STEEL C UKNOWN D 2. STAINLESS STEEL C 7.GALVANIZED STEEL <br /> C 3.PLASTIC COMPATIBLE WI CONTENTS C 99. OTHER [13. PLASTIC COMPATIBLE W/CONTENTS D 8.FLEXIBLE(HDPE) C 99. OTHER <br /> ®4.FIBERGLASS C 8.FLEXIBLE(HDPE) D 4. FIBERGLASS C 9.CATHODIC PROTECTION <br /> D 5.STEEL W/COATING D 9.CATHODIC PROTECTION 464 05 STEEL W/COATING C 95.UNKNOWN 465 <br /> VR.PIPING LEAK DETECTION(Check all that apply)(A tlescepticc al the monitonng program shall be submbeal to the local agency.) <br /> § Y) <br /> UNDERGROUND PIPING ABOVEGROUND PIPING <br /> SINGLE WALL PIPING 466 SINGLE WALL PIPING 467 <br /> PRESSURIZED PIPING(Check all that apply): PRESSURIZED PIPING(Check all that apply): <br /> 01. ELECTRONIC UNE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP SHUT OFF FOR D 1. ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP SHUT OFF FOR <br /> LEAK SYSTEM FAILURE,AND SYSTEM DISCONNECTION+AUDIBLEAND VISUAL LEAK SYSTEM FAILURE,AND SYSTEM DISCONNECTION+AUDIBLE AND VISUAL <br /> ALARMS. ALARMS. <br /> 02. MONTHLY 0.2 GPH TEST 02. MONTHLY 0.2 GPH TEST <br /> C3. ANNUAL INTEGRITY TEST(0.1GPH) 03. ANNUAL INTEGRITY TEST(0.1GPH) <br /> 04. 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): C 6. TRIENNIAL INTEGRITY TEST(0.1 GPH) <br /> [17. SELF MONITORING SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): <br /> GRAVITY FLOW C7. SELF MONITORING <br /> C 9. BIENNIAL INTEGRITY TEST(0.1 GPH) GRAVITY FLOW(Check all JI apply): <br /> C8. DAILY VISUAL MONITORING <br /> 09. 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 pre) (Check ore) <br /> Oak AUTO PUMP SHUT OFF WHEN A LEAK OCCURS Oa AUTO PUMP SHUT OFF WHEN A LEAK OCCURS <br /> C b. AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM D b AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM <br /> DISCONNECTION DISCONNECTION <br /> ®c. NOAUTO PUMP SHUT OFF Cc 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 /> ®12. ANNUAL INTEGRITY TEST(0.1 GPH) 012. ANNUAL INTEGRITY TEST(0.1 GPH) <br /> SUCTION/GRAVITY SYSTEM SUCTIONIGRAVITY SYSTEM <br /> D13, CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS C13. CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS <br /> EMERGENCY GENERATORS ONLY(Check all that appy) EMERGENCY GENERATORS ONLY(Check all that apply) <br /> [114. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF+AUDIBLE AND 014+ CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF+AUDIBLE AND <br /> VISUALALARMS VISUALALARMS <br /> 015. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)WITHOUT FLOW SHUT OFF OR <br /> RESTRICTION C 15. AUTOMATIC LINE LEAK DETECTOR(3+0 GPH TEST) <br /> [116 ANNUAL INTEGRITY TEST(0.1 GPH) D 16, ANNUAL INTEGRITY TEST(0.1 GPH) <br /> [j 17 DAILY VISUAL CHECK C17. DAILY VISUAL CHECK <br /> VIII.DISPENSER CONTAINMENT <br /> DISPENSER ®1_ FLOAT MECHANISMTHAT SHUTS OFF SHEAR VALVE <br /> CONTAINMENT El4.DAILY VISUAL CHECK <br /> DATE INSTALLED 4W D 2. CONTINUOUS DISPENSER PAN SENSOR+AUDIBLE AND VISUAL ALARMS D 5.TRENCH LINER/MONITORING <br /> 1999 D 3. CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR DISPENSER+ D 6.NONE 469 <br /> AUDIBLE AND VISUAL ALARMS <br /> Df.OWNER/OPERATOR.SIGNATURE <br /> certify that theInl ti p O,deal harem Is tru nal accurate to the best of my knowledge. <br /> SIGNATUR N OP�nTO DATE 470 <br /> C 6 ^� <br /> NAME OF OWNER/OPRATOR(print) TITLE OF OWNER/OPERATOR 472 <br /> Robert E. Hoover I Retail Environmental Administrator <br /> Pemfl Number(For local use only) 473 Farrah Approvetl(For local use only) Permit Expiration Date(For local use only) <br /> 475 <br /> UPCF (1/99 revised) Formerly SWRCB Form B <br />