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BILLING_PRE 2019
Environmental Health - Public
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2300 - Underground Storage Tank Program
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PR0231706
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BILLING_PRE 2019
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Entry Properties
Last modified
10/5/2022 3:50:41 PM
Creation date
4/2/2019 11:05:41 AM
Metadata
Fields
Template:
EHD - Public
ProgramCode
2300 - Underground Storage Tank Program
File Section
BILLING
FileName_PostFix
PRE 2019
RECORD_ID
PR0231706
PE
2361
FACILITY_ID
FA0000485
FACILITY_NAME
FLAG CITY CHEVRON
STREET_NUMBER
6421
STREET_NAME
CAPITOL
STREET_TYPE
AVE
City
LODI
Zip
95242
APN
05532024
CURRENT_STATUS
01
SITE_LOCATION
6421 CAPITOL AVE
P_LOCATION
99
P_DISTRICT
004
QC Status
Approved
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KBlackwell
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EHD - Public
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UNIFIED PROGRAM CONSOLIDATED FORM <br /> TANKS <br /> UNDERGROUND STORAGE TANKS - TANK PAGE 2 <br /> VI.PIPING CONSTRUCTION(Check alf that apply) <br /> UNDERGROUND PIPING ABOVEGROUND PIPING <br /> SYSTEM TYPE ❑ 1 PRESSURE ❑ 2. SUCTION ❑ 3. GRAVITY ❑ 1. PRESSURE ❑ 2. SUCTION ❑ 3. GRAVITY <br /> CONSTRUCTION/ ❑ 1. SINGLE WALL ❑ 3. LINED TRENCH ❑99. OTHER ❑ 1. SINGLE WALL ❑95. UNKNOWN <br /> MANUFACTURER ❑ 2. DOUBLE WALL 1195. UNKNOWN ❑ 2. DOUBLE WALL 1:199. OTHER <br /> MANUFACTURER MANUFACTURER <br /> ❑ 1.BARE STEEL ❑ 8. FRP COMPATIBLE W/100%METHANOL ❑ 1. BARE STEEL ❑ 8. FRP COMPATIBLE W/100%METHANOL <br /> MATERIALS AND ❑ 2. STAINLESS STEEL ❑ 7. GALVANIZED STEEL ❑ 2. STAINLESS STEEL ❑ 7. GALVANIZED STEEL <br /> CORROSION <br /> PROTECTION ❑ 3. PLASTIC COMPATIBLE WITH CONTENTS ❑95. UNKNOWN ❑ 3. PLASTIC COMPATIBLE WITH CONTENTS ❑ S. FLEXIBLE(HDPE) ❑99. OTHER <br /> ❑ 4. FIBERGLASS ❑ S. FLEXIBLE(HDPE) ❑99. OTHER ❑ 4. FIBERGLASS ❑ 9. CATHODIC PROTECTION <br /> ❑ 5. STEEL W/COATING ❑ 9. CATHODIC PROTECTION ❑ 5. STEEL Al COATING ❑95. UNKNOWN <br /> VII.PIPING LEAK DETECTION(Check all that apply) <br /> UNDERGROUND PIPING ABOVEGROUND PIPING <br /> SINGLE WALL PIPING SINGLE WALL PIPING <br /> PRESSURIZED PIPING(Check all thal apply): PRESSURIZED PIPING(Check all that apply): <br /> ❑ 1. ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP SHUT OFF FOR ❑ 1. ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP SHUT OFF FOR LEAK. <br /> LEAK,SYSTEM FAILURE,AND SYSTEM DISCONNECTION+AUDIBLE AND VISUAL SYSTEM FAILURE,AND SYSTEM DISCONNECTION AUDIBLE AND VISUAL ALARMS <br /> ALARMS ❑ 2. MONTHLY 0.2 GPH TEST <br /> ❑ 2. MONTHLY 0 2 GPH TEST ❑ 3. ANNUAL INTEGRITY TEST(0.1 GPH) <br /> ❑ 3. ANNUAL INTEGRITY TEST(0.1 GPH) ❑ 4. DAILY VISUAL CHECK <br /> CONVENTIONAL SUCTION SYSTEMS: CONVENTIONAL SUCTION SYSTEMS(Check all that apply): <br /> ❑ 5, DAILY VISUAL MONITORING OF PUMPING SYSTEM-TRIENNIAL PIPING INTEGRITY ❑ 5. DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM <br /> TEST(0.1 GPH) ❑ S. TRIENNIAL INTEGRITY TEST(0.1 GPHI <br /> SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING) SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): <br /> ❑ 7. SELF MONITORING ❑ 7. SELF MONITORING <br /> GRAVITY FLOW. GRAVITY FLOW(Check all that apply): <br /> ❑ 9. BIENNIAL INTEGRITY TEST(0.1 GPH) ❑ 8. DAILY VISUAL MONITORING <br /> ❑ 9. 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 <br /> (Check one) 10.CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL ALARMS AND(check one) <br /> ❑ a AUTO PUMP SHUT OFF WHEN A LEAK OCCURS ❑ a. AUTO PUMP SHUT OFF WHEN A LEAK OCCURS <br /> ❑ b AUTO PUMP SHUT OFF FOR LEAKS.SYSTEM FAILURE AND SYSTEM ❑ <br /> DISCONNECTION b. AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM DISCONNECTION <br /> ❑ c. NO ALTO PUMP SHUT OFF ❑ c. NO AUTO PUMP SHUT OFF <br /> ❑ 11. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)WITH FLOW SHUT OFF OR ❑ 11, AUTOMATIC LEAK DETECTOR <br /> RESTRICTION <br /> ❑ 12. ANNUAL INTEGRITY TEST(0.1 GPH) ❑ 12.ANNUAL INTEGRITY TEST(0.1 GPH) <br /> SUCTION/GRAVITY SYSTEM. SUCTION/GRAVITY SYSTEM: <br /> ❑ 13.CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS ❑ 13. CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS <br /> EMERGENCY GENERATORS ONLY(Check ea that apply) EMERGENCY GENERATORS ONLY(Check all that apply) <br /> ❑ 14. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF+AUDIBLE AND ❑ 14. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF+AUDIBLE AND VISUAL <br /> VISUAL ALARMS ALARMS <br /> ❑ 15 AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)WITHOUT FLOW SHUT OFF OR ❑ 15. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST) <br /> RESTRICTION <br /> ❑ 18.ANNUAL INTEGRITY TEST(0.1 GPH) ❑ 18. ANNUAL INTEGRITY TEST(0.1 GPH) <br /> ❑ 17. DAILY VISUAL CHECK ❑ 17. DAILY VISUAL CHECK <br /> Vlll.DISPENSER CONTAINMENT <br /> DISPENSER CONTAINMENT ❑ 1. FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE ❑ 4. DAILY VISUAL CHECK <br /> DATE INSTALLED ❑ 2. CONTINUOUS DISPENSER PAN SENSOR+AUDIBLE AND VISUAL ALARMS ❑ 5. TRENCH LINER/MONITORING <br /> ❑ 3. CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR DISPENSER+AUDIBLE AND VISUAL ALARMS ❑8. NONE <br /> IX.OWNER/OPERATOR SIGNATURE <br /> I certify that the information provided herein is true and accurate to the best of my knowledge. <br /> SIGNATURE OF OWNER/OPERATOR DATE <br /> NAME OF OWNER/OPERATOR(print) TITLE OF OWNERIOPERATOR <br /> Permit Number(For local use only) Permit Approved(For local use only) Permit Expiration Date(For local use only) <br /> ZZ <br /> CUPAFORM(4/99) <br /> Formerly SWRCB Form B <br />
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