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Mar 19 04 11 : 25a RH' )esign Group (92F1313-97(19 p. 10 UNIFIED PROGRAM CONSOLIDATED FORM TANKS UNDERGROUND STORAGE TANKS - TANK PAGE 2 VI.PIPING CONSTRUCDON(Chak atl that I Pagv 5 af7 UNDERGROUND PIPING ABOVEGROUND PIPING SYSTEM TYPE 0 1.PRESSURE 0 2.SUCTION ❑3.GRAVITY 08 ❑1.PRESSURE 0 2. STICTION 03.GRAVITY 459 CONSI'RUCION 1.SINGLE WALL D 3.LINED TRENCH 0 99.OTHER a60 ❑1.SINGLE WALL [195.UNKNOWN 462 MANUFAC UMR®2.DOUBLE WALL D 95.UNKNOWN 0 2.DOUBLE WALL 0 99.OTHER MANUFACTURER Western Filler' 1355 461 MANUFACTURER 463 1,BARE STEEL 06.FRP COMPATIBLE w/IOOV. METHANOL ❑1.BARE STEEL 06.FRP COMPATIBLE W/10M METHANOL2.STAINLESS STEEL. 07.GALVANIZED STEEL DUnknown 02. STAINLESS.STEEL 07.UALVANILLU STEEL ❑3.PLASTIC COMPATIBLE W1 CONTENTS 099. Other 03. PLASTIC COMPATIBLE W/CONTENTS O&.FLEXIBLE(HDPE) 099. OTHER D 4.FIBERGLASS ®8.FLEXIBLE(HOPE) 04. FIBERGLASS D 9.CATHODIC PROTECTION ❑5.STEEL W/COATING D 9.CATHODIC PROTECTION 464 D 5. STEEL W/COATING 0 95.UNKNOWN 465 VU.PIPINGI,EAKDETECTION(Chakalltlwa ly)(A dcau tion ar0rem hoti =shall be sebt,Mted W the local agemy) UNDERGROUND PIPING ABOVEGROUND PIPING SINGLE WALL PIPING 466 SINGLE WALL PIPING 467 PRESSURIZED PIPING((Meek AI that apply). PRESSURIZED PIPING(Check all Na apply) 0 1.ELLC I IONIC LINE LEAK DETP.CTOR 3.0 GPH TEST WITH AUTO PUMP SHUT 0 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+ AUDIBLE AND VISUAL ALARMS. AUDIRI,F.AND VISUAL ALARMS. [12.MONTHLY 0.2 GPH TEST 0 2. MONTHLY 0.2 GPH TEST [13.ANNUAL INTEGRITY TEST(O.IGPH) 0 3.ANNUAL IN TEST RL IGPH) D4. DAILY VISUAL CHECK CONVENTIONAL SUCITON SYSTEMS CONVENTIONAL SUCTION SYSTEMS(Cook all that appy) S.DAILY VISUAL MONITORING OF PUMPING SYS TEM+TRIENNIAL PIPING 05. DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM INTEGRITY TEST(0.1 GPH) SAFE SUCTION SYSTEMS(NO VALUES IN BELOW GxuDNDPIPING): 0 6. TRIENNIAL INTEGRITY TEST(0.1 GPH) 0 7.SELF MONITORING SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): GRAVITY FLOW [17. SELF MONITORING 0 9.BIENNIAL INTEGRITY TEST(0.1 GPH) GRAVITY PLOW(Chak all Nat apply): D R. DAILY VISUAL MONITORING 0 9. BIENNIAL INTEGRITY TEST(0.1 GPH) SECONDARILY CONTAINED PIPING SECONDARILY CONTAINED PIPING PRESSURIZED PIPING(Check all that apply) PRESSURIZED PIPING(Check all thea apply). 10. CONTINUOUS TUTU HNE SUMP SENSOR WITH AUDIBLE AND VISUAL 10. CONTINUOUS TURBINE SUMP SENSOR WITH ALUIBLE AND VISUAL ALARMS AND(LMadt em) ALARMS AND(Cluck arc) 0 a. AUTO PUMP SHUT OFF WHEN A LEAK OCCURS D a AUTO PUMP SHUT OFF WHEN A LEAK OCCURS 19b. AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM 01r AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM DISCONNECTION DISCONNECTION []c. NO AUTO PUMP SHUT OFF Oc NO AUTO PUMP SHUT OFF 11. AUTOMATIC LINE LEAK DETECTOR(LO GPH TESD WITH FLOW SHUT 0 I1 AUTOMATIC LEAK DETECTOR OFF OR RESTRICTION ®12. ANNUAL INTEGRITY TEST((11 GPH) 0 12. ANNUAL INTEGRITY TEST(0.1 GP R) SUCGON/GRAVITY SYSTEM SUCT(ON/GRAVITY SYSTEM El 13, CONTINUOUS SUMP SENSOR*AUDIBLE AND VISUAL ALARMS 013. CONTINUOUS SUMP SENSOR AUDIBLE AND VISUAL ALARMS EM ERGENCY GENERATORS ONLY(Omck NI that apply) EMERGENCY GENERATORS ONLY(Cherkall that aplgy) 0 14, CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF• D 14. CONTINUOUS SUMP SENSUR Wt I HOUT AUTO PUMP SHUT OFF AUDIBLE AND VISUAL ALARMS AUDIBLE AND VISUAL ALARMS 015. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)WITHOUT FLOW D15. AUTOMATIC LINE LEAK DETECTOR(10 GPH TEST) SHUT OFF OR RESTRICTION D 16.ANNUAL IN'TEGRLTY TEST(0.1 GPH) 0 16.ANNUAL INTEGRITY TEST(0.1 GPR) D 17. DAILY VISUAL CHECK 0 17. DAILY VISUAL CHECK VIII.DISPENSER CONTAINMENT DISPENSER CONTAINMENT OI.FLOAT MECHANISM'I HA T SHUTS OFF SHEAR VALVE ❑4.DAILY VISUAL CHECK DATE INSTALLED 46a 0 2.CONTINUOUS DISPENSER PAN SENSOR+AUDIBLE AND VISUAL ALARMS D 5.TRENCH LINER/MONITORING 2004 N 3.CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR [16.NONE 469 DISPENSER+AUDIBLE AND VISUAL ALARMS IX.OWNER/OPERATOR SIGNATURE I artily IIwL J¢iaWnmtlan pr0riJa,1 in Btrve wlaceuwmotbe 6estaL,ry knowledge. SIGNATUREOFOW ER/ TOR D a70 s+�iL ��oe NAME OF OWNER/OP TOR 471 LE OF OWNEWC ATOR 47z SAFEWAY,INC. 100 REAL ESTATE MANAGER-FUEL CENTERS P<rmR Natnber(For lool eae only) 473 Pmnit A,p cei(F.,Beal..only) 474 Pernut P.apimJan Data(F.keat me only) 475 UPCF(12/99 revised) 12 Forntaly SWRCB Form B