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Ah ' AdL <br /> MMED PROGRAM CONSOLIDATED FOMW <br /> TANKS <br /> UNDERGROUND STORAGE TANKS - TANK PAGE 2 <br /> VI.PIPING CONSTRUCTION(Chale all that I Pelee 7 of 7 <br /> UNDERGROUND PIPING ABOVEGROUND PIPING <br /> SYSTEM TYPE ®1.PRESSURE D 2.SUCTION D 3.GRAVITY 458 [11.PRESSURE D 2. SUCTION D 3,GRAVITY 459 <br /> CONSTRUCTION D 1.SINGLE WALL D 3.LINED TRENCH D 99.OTHER a60 D 1.SINGLE WALL D 95.UNKNOWN 462 <br /> MANUFACTURER ®2.DOUBLE WALL D 95.UNKNOWN D 2.DOUBLE WALL D 99.OTHER <br /> MANUFACTURER Wesrem F111e7 1655 461 MANUFACTURER 463 <br /> D 1.BARE STEEL [16.FRP COMPATIBLE w/100% METHANOL D 1.BARE STEEL D 6.FRP COMPATIBLE W/10014 METHANOL <br /> D 2.STAINLESS STEEL [17.GALVANIZED STEEL D Unknown [12. STAINLESS STEEL [17.GALVANIZED STEEL <br /> D 3.PLASTIC COMPATIBLE W/CONTENTS D 99. Other D 3. PLASTIC COMPATIBLE W/CONTENTS [18.FLEXIBLE(HOPE) [199. OTHER <br /> [14.FIBERGLASS ®8,FLEXIBLE(HOPE) [14. FIBERGLASS [19.CATHODIC PROTECTION <br /> D 5.STEEL W/COATING [19.CATHODIC PROTECTION 464 [IS. STEEL W/COATING [195.UNKNOWN 465 <br /> VII.PIPING LEAK DETECTION Chock all that I (A cription ofthe nannitoringsarognarnshall be submittal to the local cnc. <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 /> ❑1.ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP SHUT D 1. ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP <br /> OFF FOR LEAK,SYSTEM FAILURE,AND SYSTEM DISCONNECTION+ SHUT OFF FOR LEAK,SYSTEM FAILURE,AND SYSTEM DISCONNECTION+ <br /> AUDIBLE AND VISUAL ALARMS. AUDIBLE AND VISUAL ALARMS. <br /> D 2.MONTHLY 0.2 GPH TEST 02. MONTHLY 0.2 GPH TEST <br /> D 3.ANNUAL INTEGRITY TEST(O.IGPM [13.ANNUAL INTEGRITY TEST(O.1GPM <br /> [14. DAILY VISUAL CHECK <br /> CONVENTIONAL SUCTION SYSTEMS CONVEN'T'IONAL SUCTION SYSTEMS(Chock all that apply) <br /> ❑5.DAILY VISUAL MONITORING OF PUMPING SYSTEM+TRIENNIAL PIPING D 5. DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM <br /> INTEGRITY TEST(0.1 GPH) <br /> SAFE SUCTION SYSTEMS(NO VALUES IN BELOW GROUNDPIPING): D 6. TRIENNIAL INTEGRITY TEST(0.1 GPH) <br /> D 7.SELF MONITORING SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): <br /> GRAVITY FLOW D7. SELF MONITORING <br /> D 9.BIENNIAL.INTEGRITY TEST(0.1 GPH) GRAVITY FLAW(Check all that apply): <br /> [18. DAILY VISUAL MONITORING <br /> D 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 WIT I AUDIBLE AND VISUAL 10. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL <br /> ALARMS AND(Chock one) ALARMS AND(Check oac) <br /> ❑a. AUTO PUMP SHUT OFF WHEN A LEAK OCCURS D a AUTO PUMP SHUT OFF WHEN A LEAK OCCURS <br /> ®It. AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM D In AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM <br /> DISCONNECTION DISCONNECTION <br /> Dc. NO AUTO PUMP SHUT OFF Dc NO AUTO PUMP SHUT OFF <br /> ®11. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)WITH FLOW SHUT D 11. AUTOMATIC LEAK DETECTOR <br /> OFF OR RESTRICTION <br /> ®12. ANNUAL INTEGRITY TEST(0.1 GPH) ❑12. ANNUAL INTEGRITY TEST(0.1 GPH) <br /> SUCTION/GRAVITY SYSTEM SUCTION/GRAVH'Y SYSTEM <br /> O13. CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS D13. CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS <br /> EMERGENCY GENERATORS ONLY(Chock all that apply) EMERGENCY GENERATORS ONLY(Chock all that apply) <br /> D 14. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF" D 14. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF <br /> AUDIBLE AND VISUAL ALARMS AUDIBLE AND VISUAL ALARMS <br /> D 1 S. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)WITH FLOW D 15. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST) <br /> SHUT OFF OR RESTRICTION <br /> [116.ANNUAL INTEGRITY TEST(0.1 GPH) D 16.ANNUAL INTEGRITY TEST(0.1 GPH <br /> ❑17. DAILY VISUAL CHECK ❑ 17. DAILY VISUAL CHECK <br /> VIII.DISPENSER CONTAINMENT <br /> DISPENSER CONTAINMENT ❑1.FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE [14.DAILY VISUAL CHECK <br /> DATE INSTALLED 468 D 2.CONTINUOUS DISPENSER PAN SENSOR+AUDIBLE AND VISUAL ALARMS D 5.TRENCH LINER/MONITORING <br /> 2002 ®3.CONTINUOUS DISPENSER PAN SENSOR W AUTO SHUT OFF FOR D 6.NONE 469 <br /> DISPENSER+AUDIBLE AND VISUAL ALARMS <br /> IX.OWNER/OPERATOR SIGNATURE <br /> I certify,that the information provided tgM is true and aauratc to the batt ofmy knowledge. <br /> SIGNI,IrllfOR DATE 470 <br /> • IOC -�� <br /> NAME OF OWNER/OP OR(p471 TI OWNER/OPERATOR 472 <br /> tin[ <br /> SAFEWAY,INC. SOD 0, PAR REAL E STATE MANAGER-FUEL CENTERS <br /> Permit Number(For local use only) 473 Patrick Approved(Por local use only) 474 Pmrdt Expiration Date(For local use only) 475 <br /> UPCF(12/99 revised) 12 Formerly SWRCB Form B <br />