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NIFIED PROGRAM CONSOLIDATED AWM TANK UNDERGROUND STORAGE TANKS - TANK PAGE 2 V'1.PIPING CONSTRUCTION check all what apply) Page of UNDERGROUND PIPING ABOVEGROUND PIPING SYSTEM TYPE ®1.PRESSURE ❑2.SUCTION ❑3.GRAVITY 458 ❑ I.PRESSURE ❑2. SUCTION ❑3.GRAVITY 459 CONSTRUCTION ❑ I.SINGLE WALL ❑3.LINED TRENCH ❑99.OTHER 460 ❑I.SINGLE WALL ❑95.UNKNOWN 462 MANUFACTURER ®2.DOUBLE WALT. ❑95.UNKNOWN ❑2.DOUBLE WALL ❑99.OTHER MANUFACTURER TELEFLEX 461 MANUFACTURER 463 ❑1 BARE STEEI, ❑6.FRP COMPAT'LBLE w/100% MEIIIANOL ❑ 1.BARE STEEL ❑6.FRP COMPATIBLE W/100%kif-MANOL ❑2.STAINLESS STEEL ❑7.GALVANIZED STEEL I ❑Unknown ❑2. STAINLESS STEEL ❑7.GALVANIZED STEEL ❑3.PLASTIC COMPATIBLE W/CONTENTS ❑99. Other ❑3. PLASTIC COMPATIBLE W/CONTENTS ❑8.FLEXIBLE(HDPE) ❑99. OTHER ®4.FIBFRGLASS ❑8.FLEXIBLE(HDPE) ❑4. FIBERGLASS ❑9.CATHODIC PROTECTION ❑5 STEEL W/COATING ❑9.CATHODIC PROTECTION 464 ❑5 STEEL W/COATING ❑95.UNKNOWN 405 VII.PIPING LEAK DETECTION(Check all that apply)(A description of the monitoring program shall be submitted to the local agency.) UNDERGROUND PIPING ABOVEGROUND PIPING SINGLE WALL PIPING 466 SINGLE WALL PIPING 467 PRESSURIZED PIPING(Check all that apply): PRESSURIZED PIPING(Check all that apply): ❑1.ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP SHUT ❑1. ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP OFF FOR LEAK,SYSTEM FAILURF,AND SYSTEM DISCONNECTION+ SHUT OFF FOR LEAK,SYSTEM FAILURE,AND SYSTEM DISCONNECTION+ AUDIBLE AND VISUAL ALARMS. AUDIBLE AND VISUAL ALARMS. ❑2.MONTHLY 0.2 GPH TEST ❑2. MONTHLY 0.2 GPH TEST ❑3 ANNUAL INTEGRITY TEST(0.1 GPH) ❑3 ANNUAL INTEGRITY TEST(0.1 GPH) ❑4 DAILY VISUAL CHECK CONVENTIONAL SUCTION SYSTEMS CONVENTIONAL SUCTION SYSTEMS(Check all Otat apply) ❑5.DAILY VISUAL MONITORING OF PUMPING SYSTEM+TRIENNIAL PIPING INTEGRITY TFST(0.1 GPH) ❑5. DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM SAFE SUCTION SYSTEMS(NO VALUES IN BELOW GROUNDPIPING): ❑6. TRIENNIAL INTEGRITY TEST(0.1 GPH) ❑7.SELF MONITORING SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): GRAVITY FLOW ❑7. SELF MONITORING ❑9.BIENNIAL INTEGRITY TEST(0.1 GPH) GRAVITY FLOW(Check all that apply): ❑8. DAILY 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 one) ALARMS AND(Check one) Ela. AUTO PUMP SHUT OFF WHEN A LEAK OCCURS ❑a AUTO PUMP SHUT OFF WHEN A LEAK OCCURS ❑h. AUTO PUMP SI IUi'OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM ❑b AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM DISCONNECTION DISCONNECTION ®c. NO AUTO PUMP SFIUT OFF ❑c NO AUTO PUMP SHUT OFF ® 11. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)WITH FLOW SHUT OFF OR RESTRICTION ❑11. AUTOMATIC LEAK DETECTOR ®12. ANNUAL INTEGRITY TEST(0.1 GPH) ❑12. ANNUAL INTEGRITY TEST(0.1 GPH) SUCTION/GRAVITY SYSTEM SUCTION/GRAVITY SYSTEM ❑13. CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS ❑13. CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS EMERGENCY GENERATORS ONLY(Check all that apply) EMF,RGENCV GENERATORS ONLY(Check all that apply) ❑14. CONTINUOUS SUMP SENSOR WITH AUTO PUMP SHUTOFF* ❑14. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF AUDIBLE AND VISUAL ALARMS AUDIBLE AND VISUAL ALARMS ❑15. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)WITHOUT FLOW ❑I5. AUTOMATIC LINE LEAK DETECTOR 3 0 GPH TEST SHUT OFF OR RESTRICTION ( ) ❑16.ANNUAL INTEGRITY TEST(0.1 GPH) ❑ 16.ANNUAL INTEGRITY TEST(0.1 GPH) ❑17 DAILY VISUAL CHECK ❑17. DAILY VISUAL CHECK VIII.DISPENSER C''ONTAINMENT DISPENSER CONTAINMENT ® 1.FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE ❑4.DAILY VISUAL CHECK DATE INSTALLED 468 ❑2.CONTINUOUS DISPENSER PAN SENSOR+AUDIBLE AND VISUAL ALARMS ❑5.TRENCH LINER/MONITORING 1994 ❑3.CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SFR IT OFF FOR ❑6.NONE 4.9 DISPENSER+AUDIBLE AND VISUAL ALARMS IN.OWNER/OPERATOR SIGNATURE I certify that the infon»alion provided hercbt is We and accurate to the best of my knowledge. SI' I'UItE OWN O AERATORI DATTT�� llJ1 - 9--0'3 470 NAME OF OWNS OI'RATOR(print) TLE OF OWNER/OPERATOR 472 SANDY EDWARDS '-�Cl QL t TPJ �(Qk Pen»il Ntunber(For local use only) 473 Pemut Approved(For local use only) Permit liapiration Date(RQJ local use only) 475 UPCF(1/99 revised) Formerly SWRCB Form B