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�0FIED PROGRAM CONSOLIDATED FqV TANKS UNDERGROUND STORAGE TANKS- TANK PAGE 2 VI.PIPING CONSTRUCTION(Cnukall ttmt iy) Poge_or_ UNDERGROUND PIPING ABOVEGROUND PIPING SYSTEM TYPE 19I.PRESSURE [12.SUCTION ❑3.GRAVITY 459 ❑1.PRESSURE ❑2. SUCTION ❑3.GRAVITY 459 CONSTRUCTION [11.SINGLE WALL ❑3.LINED TRENCH ❑99.OTHER 460 ❑ I.SINGLE WALL ❑95.UNKNOWN 462 MANUFACTURER J92.DOUBLE WALL [195.UNKNOWN ❑2.DOUBLE.WALL ❑99.OTHER MANUFACTURER 461 MANUFACTURER 463 ❑1.BARE STEEL [16.FRP COMPATIBLE w/I oV% METHANOL ❑ 1.BARE STEEL ❑6.FRP COMPATIBLE whoa.METHANOL. ❑2.STAINLESS STEEL [17.GALVANIZED STEEL ❑Unknown [:12. STAINLESS STEEL [17.GALVANIZED STEEL ❑3.PLASTIC COMPATIBLE W/CONTENTS ❑99. Outer ❑3. PLASTIC COMPATIBLE WI CONTENTS ❑8.FLEXIBLE(HDPF,) ❑99. OTHL•R ((4.FIBERGLASS ❑8.FLEXIBLE(HDPE) ❑4. FIBERGLASS ❑9.CATHODIC PROTECTION [15.STEEL W/COATING [19.CATHODIC PROTECTION 464 [15. STEEL W/COATING ❑95.UNKNOWN 465 VII.PIPING LEAK DETECTION(Cheek all that apply)(Adtscri tion ofthe monitoting program shall be submitted to the local a ncy.) UNDERGROUND PIPING ABOVEGROUND PIPING SINGLE WALL PIPING 466 SINGLE WALL PIPING 467 PRESSURIZED PIPING(Chock all that apply): PRESSURIZED PIPING(Cheek all that apply): ❑1_ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WhrH 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 i. 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.IGPH) ❑3.ANNUAL INTEGRITY TEST(0.1 GPH) ❑4. DAILY VISUAL CHECK CONVENTIONAL SUCTION SYSTEMS CONVENTIONAL SUCTION SYSTEMS(Check all that apply) ❑5.DAILY VISUAL MONITORING OF PUMPING SYSTEM+TRIENNIAL PIPING [:15. DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM INTEGRITY TEST(0.1 GPH) SAFE SUCTION SYSTEMS(NO VALUES IN BELOW GROUNDPIPING): [16. TRIENNIAL INTEGRITY TEST(0.1 GPH:I ❑7.SELF MONITORING SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): GRAVITY FLOW ❑7. SELF MONITORING ❑9.BIENNIAL INTEGRITY TEST(O.I GPH) GRAVITY FLOW(Check all that apply): ❑8. DALLY VISUAL MONITORING ❑9. BIENNIAL INTEGRITY TEST(0.1 GPH) SECONDARILY CONTAINED PIPING SECONDARILY CONTAINED PIPING PRESSURIZED PIPING(Check all that apply): PRESSURIZED PIPING(Check all that apply): 10. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL 10. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL ALARMS AND(Check on c) ALARMS AND(Check one) ❑a. AUTO PUMP SHUT OFF WHEN A LEAK OCCURS ❑a AUTO PUMP SHUT OFF WHEN A LEAK OCCURS IX b. AuTo PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM ❑b AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM DISCONNECTION DISCONNECTION ❑c. NO AUTO PUMP SHUTOFF ❑c NO AUTO PUMP SHUT OFF ((f 11. AUTOMATIC UNE LEAK DETECTOR(3.0 GPH TEST)WITH FLOW SHUT ❑It. AUTOMATIC LEAK DETECTOR OFF OR RESTRICTION ❑ 12. ANNUAL INTEGRITY TEST(0.1 GPH) ❑12 ANNUAL INTEGRITY TEST(0.1 GPH) SUCTIOWGRAVITY SYSTEM SUCTION/GRAVITY SYSTEM ❑13. CONTINUOUS SUMP SENSOR+AUDIBL.E AND VISUAL ALARMS ❑ 13. CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS EMERCENCY GENERATORS ONLY(Chock.11 tlmt apply) EMERGENCY GENERATORS ONLY(Check all that apply) ❑14. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUTOFF ❑14. CONTINUOUS SUMP SENSOR WITHOUT AUTOPUMP SHUT OFF" AUDIBLE AND VISUAL ALARMS AUDIBLE AND VISUAL ALARMS ❑15. AUTOMATIC LINE LFAK DETECTOR(3.0 GPH TESL')W1 H UT FLOW [115. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST) SHUTOFF OR RESTRICTION ❑16.ANNUAL INTEGRITY TEST(0.l GPH) ❑16.ANNUAL INTEGRITY TEST(0.1 GPH) ❑17. DAILY VISUAL CHECK ❑17. DAILY VISUALCHECK VIII.DISPENSER CONTAINMENT DISPENSER CONTAINMENT ❑1.FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE, [:14.DAILY VISUAL CHECK DATE INSTALLED 468 ❑2.CONTINUOUS DISPENSER PAN SENSOR 4.AUDIBLE AND VISUAL ALARMS ❑5.TRENCH LINER i MONITORING [83.CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUTOFF FOR []6.NONE 469 DISPENSER+AUDIBLE AND VISUAL ALARMS IX.OWNER/OPERATOR SIGNATURE l anify that the infortnal;on provided herein is truer and accurate to the best ormy kntowl dge SIGNATURE OF O ER/OPERATJDRt DATE 470 NAME OF OWNER'OPRATOR(print) 471 TITLE OF OWNER/OPERATOR 472 �P=ermitNumber(For local use only) 473 Permit Approved(For local use only) 474 Pamit Expiration Date(For local use only) 475 UPCF(12/99 revised) 12 Formerly SWRCB Form B C-d WZZ-99,b-60Z }y61M eougjme� dee:oL 80 t,0 ue