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03/17/2004 10:23 2099310560 CHEVRON 1580 <br />us�•,:� '1'� [. �, a <br />V11 1`11 <br />UNDERGROUND PIPiNQ <br />SYSTEM TYPt, 0 1. PRESSURE: <br />CONS'fR(r( r10N ❑ 1. SINGLE WALL <br />SIAMIFAC IUtPR ® 2. DOUBLE WALL <br />❑ 2. SUCTION ❑ 3. GRAVI'T'Y 431 <br />❑ .3. LINED'FRENCH ❑ 99.OTHtR 46o <br />❑ 95. UNKNOWN <br />❑ I. BARE STEEL <br />❑ 6. FRP COMPATIBLE wfl ooAA METHANOL <br />0 2; !R'AINLkSS STEEL <br />❑ 7. GALVANIZED STEEL ❑ Unknown <br />[13, PI.A%TJC COMPATIBLE W/ CONTENTS ❑ 99. Other <br />0 4. FIBERGLASS <br />❑ S. FLEXIBLE (HDPE) <br />[] 5. STEEL W/COATING <br />❑ 9. CATI30IJ)C PROTECTION 464 <br />VII. PIPING LEAK DETECTION (che kell <br />PAGE 05/05 <br />4Of4 <br />ABOVEOROUND PIPINU <br />❑ I.I'RIi5SURE ❑ 2. SUCTION _ E13, GRAVI'T'Y +sv <br />❑ ISINGLJ.i WALT, C3 95. UNKNOWN 4a; <br />❑ 2, DOUBT.,F WALL. ❑ 99.OTHFR <br />461 I MANUFACTURtR <br />❑ I . BARE. STEEL, <br />0 2. STAINLESS STEEL. <br />EJ 3, PLASTIC COMPATIDLE W/ CONTENTS <br />❑ 4. FIBERGLASS <br />115, STEEL W/COATING <br />,apply) (A desci iption of the monliorinq orotirAm Snell bo et <br />$INGLIE WALL PIPING 466 <br />PRESSURIZED PIPING (Check all that apply): <br />❑ 1. ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST EU AUTO PUMP SLUT <br />OFF FOR LEAK, SYSTEM FAILURE, AND SYSTEM DISCONNECTION 4. <br />AUDIBLE AND VISUAL ALARMS, <br />0 2. MONTHLY 0.2 GPH TEST <br />[13. ANNUAL INTEGRITY TEST (0.1 GPH) <br />CONVENTIONAL SUCTION SYSTEMS <br />❑ 5. DAILY VISUAL, MONITORING OF PUMPING SYS'fF.M - TRIENNIAL PIPING <br />INTEGRITY TEST (0.1 GPH) <br />SAFE SUCTION SYSTEMS (NO VALUES IN BELOW GROUND PIPING): <br />[17. SELF MONITORING <br />GRAVITY FLOW <br />❑ 9. BIENNIAL INTEGRITY PEST (0.1 GPH) <br />FLCONDA,RILY CONTAINED PIPING <br />PRESSURIZED PIPING (Chick Othat apply)' <br />10. CONTINUOUS TURBINE SUMP SENSOR =1 1 AUDIBLE AND VISUAL <br />ALARMS ANI) (Check one) <br />® a. AUTO PUMP S}RJT OFF WHIN A LEAK OCCURS <br />® b. AUTO PUMP SHUT OFT' FOR LEAKS, SYSTEM FAILURE AND SYSTEM <br />DISCONNECTION <br />Qc. NO AUTO PUMP SHUT OFT <br />11. AUTOMATIC LINE LEAK DETECTOR (3.0 GPH TEST) WITH FLOW SHUT <br />OFF OR RESTRICTION <br />❑ 12. ANNUAL INTEGRITY TEST (0.1 GPH) <br />SUCTION/GRAVITY SYSTEM <br />❑ 13. CONTINUOUS SUMP SENSOR + AUDIBLE AND VISUAL ALARMS <br />EMERGENCY GENERATORS ONLY (Chock all that apply) <br />❑ 14. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUTOFF � <br />AUDIBLE AND VISUAL ALARMS <br />❑ 15. AUTOMATIC 1,INF. I,FAK DFTFCTOR (4 0 GPH TEST) _WjTUQja FLOW <br />SHUTOFF OR RESTRICTION <br />�] )6• ANNUAL; INT'E.GRITY TES <br />❑ 17. DAILY VISUAL.. CHECK <br />DISPENSER CONTA,INMtNT <br />DATF INST.A.LI: FO aRa <br />1998 <br />I certify that the information provided herei <br />SIGNATURE OF OWNER) <br />0• X. LDRI <br />Chevron Products <br />Permit Nutftb^cr (For Ideal use <br />_ 4G3 <br />❑ 6. FRP COMPATIBLE lti/lQ0oio METHANOT. <br />Q 7, GALVANIZED STEEL, <br />® S. FLEXIBLE' (HDPE) 0 99. OTHER <br />❑ 9. CATHODIC PROTECTION <br />❑ 95. UNKNOWN 465 <br />:od to the focal aaencv.'1 <br />SINGLE WF%I.I_, PIPING 467 <br />PRESSURIZED PI]>RJG (Check au than Apply): <br />❑ ), ELECTRONIC LINE LEAK DETECTOR3.0 GP}I I'IiST WITH AUTO PtJMF <br />SHUT OFF FOR LEAK, SYSTEM FAILI,TR$, AND SYSTEM DISCONNECTION + <br />AUDIBLE AND VISUAL ALARMS. <br />❑ 2. MONTHLY 0.2 GPH TEST <br />❑ 3. ANNUAL INTEGRITY TES T (0.1 GPH) <br />❑ 4. DAILY vtSt.)AL CHECK <br />CONVENTIONAL $iJCT10N $YS'CkMS (Check at) chat apply) <br />05 DAILY VISUAL MONYTOR[NG QF PIPING ANI) PVMYIN(r SYSTEM <br />❑ 6. TRIENNIAL INTEGRITY TEST (O.I GPH) <br />SAFE SUCTION SYSTEMS (NU VALVES EV BELOW GROUND PIPING); <br />❑ 7. SELF MONITORING <br />(i)tAV I'I'Y t'LUw (Check all (hat apple): <br />❑ 8. i)nII.Y VISr1Ar.MrlNiTnRnvG <br />❑ 4. BIENNIAL INTFGRC1'Y TEST (O.l GPM) <br />SECONDARILY CONTAINED PIPING <br />PRE.S5i1RI7.L"I) PIPING ('l''hak all that apply): <br />10. CONTINt1UU5'I'UItL3INE SUMP SENSOR �YJII•I AVDCBLE AND VISUAL, <br />ALARMS AND (Cheek one) <br />❑ a AUTO PUMP SHUT OFF WHEN A LEAK OCCURS <br />❑ b AUTO PUMP SHUT OFF FOR LEAKS, SYSTEM FAILURE, AND SYSTEM <br />DISCONNECTION <br />❑c NO AUTO PUMP SHUT OFF <br />❑ 31. AUTOMATIC LEAK DETECTOR <br />❑ 12. ANNUAL (NTtiGRI'I'Y 7ESI' (O.t GPO) <br />SUCI"LUN/GRAVITY SYSTEM <br />❑ 13. CONTINUOUS SUMP SENSOR •+AUDIBLE AND VISUAL ALARMS <br />EMERGENCY GENERATORS ONLY (Check all that apply) <br />❑ 14. CONTIN(JO115 5(1MP SENSpR WITHOUT AUTO PUMP SHUT OFF ° <br />A11DIIiL£ AND VISUAL ALARMS <br />Q 15, Al.l /'OMA I !(: I,1N> LEAK t)h' I'kC'1'UK (3.0 <br />T (0.1 GP.H) ❑ 16. ANNUAL, INTEGRd'FY TEST (0.1 GPH) <br />❑ 17. DAILY VISUAL CHF,.CK <br />VIII. DISPENSER CONTAINMENT <br />El I - FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE ❑ 4. DAIL <br />M 2. CONTINUOUS DISPENSFR PAN SENSOR +AUDIBLE AND VISUAL, ALARMS ❑ S. TREN <br />(D 3. CONTINUOUS DISPENSER PAN SENSOR WnI AUTO SHUT OFF FOR 6, NONE <br />DISPENSER + AVDIBL1: AND VISUAL ALARMS El <br />_ IX. (3WNERIOPERATOR SIGNATURE <br />n is trot: ancurate a beat of my know'lod8e .-.w..� <br />--- DATE <br />9/3/02 <br />~- TITI.E OF OWNERJpPERATOR <br />I /D. R. LERI Retail ESN Specialist <br />473 Permit Approved (For local use only) permit Expiration I <br />(sPH I F,S I ) <br />Y VISUAL CHECK. <br />CH LINER!' MONITORING <br />�i <br />969 <br />tJPCF 4I/99 revised) 176 Forltilrr.ly 5Vv'RC'B Form B <br />