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ED PROGRAM CONSOLIDATED SITE#2611195/11195/30225 PIPING UNDERGROUND STORAGE TANKS - TANK PAGE 2 VI.PIPING CONSTRL CTION(Check all that apply) Page of UNDERGROUND PIPING ABOVEGROUND PIPING SYSTEM TYPE RESSURE ❑2.SUCTION ❑3.GRAVITY 458 ❑l.PRESSURE ❑2.SUCTION ❑3.GRAVITY 459 [11.SINGLE WALL ❑3.LINED TRENCH [:199.OTHER 460 E:1 1.SINGLE WALL ❑95.XERXES 462 CONSTRUCTION/ 2,DOUBLE WALL ❑95.XERXES [12.DOUBLE WALL ❑99.OTHER MANUFACTURER MANUFACTURER 461 MANUFACTURER 463 [:11.BARE STEEL ❑6.FRP COMPATIBLE w/100%METHANOL [:11.BARE STEEL ❑6.FRP COMPATIBLE W/100%METHANOL MATERIALS AND ❑2.STAINLESS STEEL ❑7.GALVANIZED STEEL ❑2.STAINLESS STEEL ❑7.GALVANIZED STEEL CORROSION ❑3PLASTIC COMPATIBLE WITH CONTENTS E:195.XERXES E13.PLASTIC COMPATIBLE WITH CONTENTS [:18.FLEXIBLE(HDPE) 099.OTHER PROTECTION FIBERGLASS ❑8.FLEXIBLE(HDPE) E:199.OTHER ❑4. FIBERGLASS ❑9.CATHODIC PROTECTION ❑5.STEEL W/COATING ❑9.CATHODIC PROTECTION 464 ❑5. STEEL W/COATING ❑95. XERXES 465 VII.PIPING LEAK DETECTION(Check all that apply)(A description ojthe monitoring program shall he submitted to the local agency) UNDERGROUND PIPING ABOVEGROUND PIPING SINGLE WALL PIPING SINGLE WALL PIPING 467 PRESSURIZED PIPING(Check all that apply): PRESSURIZED PIPING(Check all that apply): ❑ I. 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, LEAK,SYSTEM FAILURE,AND SYSTEM DISCONNECTION+AUDIBLE AND VISUAL SYSTEM FAILURE,AND SYSTEM DISCONNECTION+AUDIBLE AND VISUAL ALARMS 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(Check all that apply): CONVENTIONAL SUCTION SYSTEMS: ❑ 5. DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM ❑ 5 DAILY VISUAL MONITORING OF PUMPING SYSTEM+TRIENNIAL PIPING INTEGRITY TEST(0.1 GPH) ❑ 6. TRIENNIAL INTEGRITY TEST(0.1 GPH) SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): ❑ 7. SELF MONITORING ❑ 7. SELF MONITORING GRAVITY FLOW: GRAVITY FLOW(Check all that apply): ❑ 9. BIENNIAL INTEGRITY TEST(0.1 GPH) ❑ 8. DAILY VISUAL MONITORING ❑ 9. BIENNIAL INTEGRITY TEST(O.1 GPH) SECONDARILY CONTAINED PIPING SECONDARILY CONTAINED PIPING PRESSURIZED PIPING(Check all that apply): PRESSURIZED PIPING(Check all that apply): 10 CON"FINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL ALARMS AND 10. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL ALARMS AND(check one) (Check one) ❑ a. AUTO PUMP SHUT OFF WHEN A LEAK OCCURS ❑ a. AUTO PUMP SHUT OFF WHEN A LEAK OCCURS ❑ b. AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM DISCONNECTION AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM ❑ c. NO AUTO PUMP SHUT OFF DISCONNECTION ❑ 11. AUTOMATIC LEAK DETECTOR ❑ c. NO AUTO PUMP SHUT OFF ❑ 12. ANNUAL INTEGRITY TEST(0.1 GPH) I. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)WITH FLOW SHUT OFF OR RESTRICTION SUCTION/GRAVITY SYSTEM: ❑ 12. ANNUAL INTEGRITY TEST(0.1 GPH) ❑ 13. CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS SUCTION/GRAVITY SYSTEM: EMERGENCY GENERATORS ONLY(Check all that apply) ❑ 13. CONTINUOUS SUMP SENSOR,AUDIBLE AND VISUAL ALARMS ❑ 14. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF+AUDIBLE AND VISUAL ALARMS EMERGENCY GENERATORS ONLY(Check all that apply) ❑ 15. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST) ❑ 14. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF+AUDIBLE AND VISUAL ALARMS ❑ 16. ANNUAL INTEGRITY TEST(0.1 GPH) ❑ 15. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)WITHOUT FLOW SHUT OFF OR ❑ 17. DAILY VISUAL CHECK RESTRICTION ❑ 16. ANNUAL INTEGRITY TEST(0.1 GPH) ❑ 17. DAILY VISUAL CHECK VIII.DISPENSER CONTAINMENT 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 ❑ 3.CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR DISPENSER+AUDIBLE AND VISUAL ALARMS ❑ 6.NONE 469 IX.OWNER/OPERATOR SIGNATURE I certify that the information provided herein is true and accurate to the best of my knowledge. SIGN OF O R/OPERATOR DATE 470 NAME O WNE OPERATO (print) 471 TITLE O OWNER/OPERATOR 472 JANETTE M.THOMPSON FOR CIRCLE K STORES,INC. COMPLIANCE SPECIALIST Permit Number(For local use only) 473 Perrrit Approved(For local use only) 474 1 Pertnit Expiration Date(For local use only)475