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FIED PROGRAM CONSOLIDATED FORM loci TANKS W UNDERGROUND STORAGE TANKS-TANK PAGE 2 f' Pag,5 If 7 VL PIPING CONSTRUCTION(ched an that apply) UNDERGROUND PIPING ABOVEGROUND PIPING SYSTEM TYPE -0 1.PRESSURE ❑2.SUCTION ❑3.GRAVITY 459. [3 1.PRESSURE 0 2.SUCTION [13.GRAVITY 459. CONSTRUCTION/ [11.SINGLE WALL ❑3.LINED TRENCH 99.OTHER 460. EILSINGLE WALL 0 95.UNKNOWN 462. MANUFACTURER [3 2.DOUBLE WALL ❑95.UNKNOWN [3 2.DOUBLE WALL 13 99.OTHER MANUFACTURER 461- . MANUFACTURER 463. ❑1.BARE STEEL 0 6.FRP COMPATIBLE W/100%METHANOL [11.BARE STEEL 0 6.FRP COMPATIBLE W/100%METHANOL ❑2.STAINLESS STEEL [:)7.GALVANIZED STEEL [3 2.STAINLESS STEEL 13 7.GALVANIZED STEEL ❑3.PLASTIC COMPATIBLE WITH CONTENTS [3 95.UNKNOWN 0 3.PLASTIC COMPATIBLE W1 CONTENTS 0 8.FLEXIBLE(HDPE) [3 99.OTHER 0 4.FIBERGLASS [18.FLEXIBLE(HDPE) [199.OTHER [14.FIBERGLASS 0 9.CATHODIC PROTECTION 0 5.STEEL W/COATING [3 9.CATHODIC PROTECTION 464. 0 5.STEEL W/COATING [3 95.UNKNOWN 465. VII.PIPING LEAK DETECTION(Check all that apply)(A dacripcion of the maniWring 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): 0 1. ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP [3 1. ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP SHUT-OFF FOR LEAK,SYSTEM FAILURE,AND SYSTEM DISCONNECTION SHUT OFF FOR LEAK,SYSTEM FAILURE,AND SYSTEM DISCONNECTION +AUDIBLE AND VISUAL ALARMS. +AUDIBLE AND VISUAL ALARMS. 0 2. MONTHLY 0.2 GPH TEST 02. MONTHLY 0 7 GPH TEST [13. ANNUAL INTEGRITY TEST(0.1 GPH) E3 3. ANNUAL INTEGRITY TEST(0.1 GPH) [34. DAILY VISUAL CHECK CONVENTIONAL SUCTION SYSTEMS CONVENTIONAL SUCTION SYSTEMS(Check all that apply) ❑5. DAILY VISUAL MONITORING OF PUMPING SYSTEM+TRIENNIAL PIPING [35. DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM INTEGRITY TEST(0.1 GPH) SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): [36. TRIENNIAL INTEGRITY TEST(0.1 GPH) [17. SELF MONITORING SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): GRAVITY FLOW [3 7. SELF MONITORING 09. BIENNIAL INTEGRITY TEST(0.1 GPH) GRAVITY FLOW(Check all that apply): 0 8. DAILY VISUAL MONITORING 09, 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) [3 a. AUTO PUMP SHUT OFF WHEN A LEAK OCCURS [3 a. AUTO PUMP SHUT OFF WHEN A LEAK OCCURS ❑b. AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM [3 b.AUTO PUMP SHUTOFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM DISCONNECTION DISCONNECTION Oc. NO AUTO PUMP SHUT OFF Oc. NO AUTO PUMP SHUT OFF [3 11. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)WITH FLOW SHUT D I I.AUTOMATIC LEAK DETECTOR OFF OR RESTRICTION ❑12. ANNUAL INTEGRITY TEST(0.1 GPH) 0 12.ANNUAL INTEGRITY TEST(0.1 GPH) SUCTION/GRAVITY SYSTEM SUCTION/GRAVITY SYSTEM 0 13. CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS 0 13.CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS EMERGENCY GENERATORS ONLY(Check all that apply) EMERGENCY GENERATORS ONLY(Check all that apply) [314. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF [3 14.CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF AUDIBLE AND VISUAL ALARMS AUDIBLE AND VISUAL ALARMS [315. AUTOMATIC LINE LEAK DETECTOR (3.0 GPH TEST) WITHOUT FLOW 13 15.AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST) SHUT OFF OR RESTRICTION [316. ANNUAL INTEGRITY TEST(0.1 GPH) [3 16.ANNUAL INTEGRITY TEST(0.1 GPH) El 17. DAILY VISUAL CHECK 0 17. DAILY VISUAL CHECK VIII.DISPENSER CONTAINMENT DISPENSER CONTAINMENT 468. [] 1. FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE [3 4. DAILY VISUAL CHECK 469. DATE INSTALLED [12. CONTINUOUS DISPENSER PAN SENSOR+AUDIBLE AND VISUAL ALARMS ❑5. TRENCH/LINER MONITORING [13. CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR 6. NONE DISPENSER+AUDIBLE AND VISUAL ALARMS IX OWNER/OPERATOR SIGNATURE I certify that the information provided herein is true and accurate to the best of my knowledge. SIGNA EO AA-&"�f DATE: l7 470. • / Obl0 J NAME OF OWNER/OPERATOR(print): Tom Piskor(Agent for Shell) TITLE OF OWNER/OPERATOR: Project Manager 472. Permit Number(Agency use only) 473. 1 Permit Approved By(Agency use only) 474. 1 Permit Expiration Date(Agency use only) 475 UPCF hwfwrc-b(1/99)-3/4 http://www.unidocs.org Rev.02/16/00