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UNIFIED PROGRAM CONSOLIDATED FORW TANK UNDERGROUND STORAGE T - TANK PAGE 2 'VI.PIPING CONSTRUCTION(Check all that apply) Page_of UNDERGROUND PIPING ABOVEGROUND PIPING SYSTEM TYPE ®1.PRESSURE ❑2.SUCTION ❑3.GRAVITY 458 ❑1.PRESSURE ❑2. SUCTION ❑3.GRAVITY 459 CONSTRUCTION/ ❑1.SINGLE WALL ❑3.LINED TRENCH [199.OTHER 460 ❑1.SINGLE WALL ❑95.UNKNOWN 462 MANUFACTURER ®2.DOUBLE WALL ❑95.UNKNOWN ❑2.DOUBLE WALL ❑99.OTHER MANUFACTURER 461 MANUFACTURER 463 ❑1 BARE STEEL ❑6.FRP COMPATIBLE w/too/ METHANOL ❑1.BARE STEEL ❑6.FRP COMPATIBLE W1100/METHANOL ❑ 2.STAINLESS STEEL ❑7.GALVANIZED STEEL ❑UKNOWN ❑2. STAINLESS STEEL ❑7.GALVANIZED STEEL ❑3.PLASTIC COMPATIBLE W/CONTENTS ❑99 OTHER ❑3. PLASTIC COMPATIBLE W/CONTENTS ❑8.FLEXIBLE(HDPE) [:199. OTHER ®4.FIBERGLASS ❑8.FLEXIBLE(HDPE) ❑4. FIBERGLASS ❑9.CATHODIC PROTECTION ❑5.STEEL W/COATING [:19.CATHODIC PROTECTION 464 ❑5. STEEL WICOATING ❑95.UNKNOWN 465 .VII.PIPING LEAK DETECTION(Check all that apply)(A description of the monitoring program shalfbesubmitted.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 OFF FOR ❑1. ELECTRONIC UNE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP SHUT OFF FOR LEAK,SYSTEM FAILURE,AND SYSTEM DISCONNECTION+AUDIBLE AND`IISUAL LEAK.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(0.1GPH) ❑3. ANNUAL INTEGRITY TEST(0.1GPH) [14. DAILY VISUAL CHECK CONVENTIONAL SUCTION SYSTEMS CONVENTIONAL SUCTION SYSTEMS(Check all that apply) C35. DAILY VISUAL MONITORING OF PUMPING SYSTEM+TRIENNIAL PIPING INTEGRITY C15. DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM TEST(0.1 GPH) SAFE SUCTION SYSTEMS(NO VALUES IN BELOW GROUNDPIPING): ❑6. TRIENNIAL INTEGRITY TEST(0.1 GPH) ❑i. 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): E18. DAILY VISUAL MONITORING ❑9. BIENNIAL NTE-PITY TEST(0.1 GPH) SECONDARILY CONTAINED PIPING I SECONDARILY CONTAINED PIPING i PRESSURIZED PIPING(Check all the apply! PRESSURIZED P!P!NG ICI eck all that apply) 10- CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND IISLA-.ALARMS AND 10. CONTINUOUS TijRBINE SUMP SENSOR WITH AUDIBLE AND VISUAL ALARMS AND (Check oriel j Check one! ❑a T PI lMr Si UT OFF WHEN A LEAK OCCURS j ❑a AUT PUMP SHUT OFF WHEN A LEAK OCCURS ®o uTO PUMP SHUT OFF FC,R LEAKS.SYSTEM FAILURE tND SYSTEM ❑c ,' SMP SHUT OFF FOR LEAKS.SYSTEM FAILURE AND SYSTEM i DISCONNECTION D,SC ,NE-_TION ❑c. NO AUTO PUMP SHUT OFF ❑c NO t-T-_PUMP SHUT OFF C311. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)WITH FLO!A'SHUTOFF OR ❑11. AUTOMATIC LEAK DETECTOR RESTRICTION ❑12. ANNUAL INTEGRITY TEST(0.1 GPH) ❑12. ANNUAL INTEGRITY TEST(0.1 GPH) SUCTION/GRAVITY SYSTEM SUCTION/GRAVITY SYSTEM C3 13. CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS 01 CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS EMERGENCY GENERATORS ONLY(Check all that apply) EMERGENCY GENERATORS ONLY(Check all that apply) ❑14. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF+AUDIBLE AND ❑14. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF-AUDIBLE AND VISUAL ALARMS VISUAL ALARMS ❑15. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)WITHOUT FLOW SHUT OFF OR ❑15. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST) RESTRICTION [:116. ANNUAL INTEGRITY TEST(0.1 GPH) ❑16. ANNUAL INTEGRITY TEST(0.1 GPH) ❑17 DAILY VISUAL CHECK ❑17. DAILY VISUAL CHECK VIII:DISPENSER CONTAINMENT DISPENSER ❑1. FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE ❑4.DAILY VISUAL CHECK CONTAINMENT DATE INSTALLED 468 C12. CONTINUOUS DISPENSER PAN SENSOR,AUDIBLE AND VISUAL ALARMS ❑5.TRENCH LINER(MONITORING 03. CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR DISPENSER+ ❑6.NONE 469 AUDIBLE ANDVISUAL ALARMS IX.OWNER/OPERA ,SIGNATURE I certify that the iniorr,ation,rovided herein is tr and a cu to th best my knowledge. SIGNA-URE C= 5PE ATOR" A DATE 7p 470 ` r r--- -; - l I �RATOR 472 Jack Rhoaces Director of L^rineering Permit Nw�ber-Fc oc i s--^ " '-3 P,-, Aooroved fFor local use only) Permit Expiration Date For local use only) a75 _Adlk