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871-D1U2 v IFIED PROGRAM CONSOLIDATED FOR TANKS UNDERGROUND STORAGE TANKS -TANK PAGE 2 2 of 2 V1.PIPING CONSTRUCTION(Check aB that appy) UNDERGROUND PIPING ABOVEGROUND PIPING SYSTEM TYPE ❑ 1 PRESSURE ® 2. SUCTION ® 3. GRAVITY ❑ 1. PRESSURE fI 2. SUCTION 91 3. GRAVITY CONSTRUCTION/ ❑ 1. SINGLE WALL ❑ 3. LINED TRENCH ❑99. OTHER S,I 1 SINGLE WALL E-195. UNKNOWN MANUFACTURER IX2. DOUBLE WALL ❑95. UNKNOWN ❑ 2. DOUBLE WALL 1199. OTHER MANUFACTURER T6tq.j C--9� � e-F MANUFACTURER ❑ 1.BARE STEEL ❑ S. FRP COMPATIBLE W/100%METHANOL ❑ 1. BARE STEEL ❑ 8. FRP COMPATIBLE W/100%METHANOL MATERIALS AND ❑ 2. STAINLESS STEEL ❑ 7. GALVANIZED STEEL ❑ 2. STAINLESS STEEL ❑ 7. GALVANIZED STEEL CORROSION - PROTECTION ❑ 3. PLASTIC COMPATIBLE WITH CONTENTS ❑95. UNKNOWN ❑ 3. PLASTIC COMPATIBLE WITH CONTENTS ❑ 8. FLEXIBLE(HDPE) ❑99. OTHER ❑ 4. FIBERGLASS ID 8. FLEXIBLE(HDPE) ❑99. OTHER ❑ 4. FIBERGLASS ❑ 9.CATHODIC PROTECTION ❑ 5. STEEL W/COATING ❑ 9. CATHODIC PROTECTION I Q 5.STEEL W/COATING 1195. UNKNOWN VII.PIPING LEAK DETECTION(Check all that appy) UNDERGROUND PIPING ABOVEGROUND PIPING SINGLE WALL PIPING SINGLE WALL PIPING PRESSURIZED PIPING(Check all that appy): PRESSURIZED PIPING(Check all that appy): - ❑ 1. ELECTRONIC LINE LEAK DETECTOR 3.0 GPM TEST WITH AUTO PUMP SHUT OFF FOR ❑ 1. ELECTRONIC LINE LEAK DETECTOR 3.0 GPM 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 GPM TEST ❑ 2. MONTHLY 0.2 GPH TEST ❑ 3. ANNUAL INTEGRITY TEST(0.1 GPM) ❑ 3.ANNUAL INTEGRITY TEST(0.1 GPM) ❑ 4. DAILY VISUAL CHECK CONVENTIONAL SUCTION SYSTEMS: CONVENTIONAL SUCTION SYSTEMS(Check a/1 that apply): ❑ 5. DAILY VISUAL MONITORING OF PUMPING SYSTEM+TRIENNIAL PIPING INTEGRITY ❑ 5. DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM TEST(0.1 GPM) ❑ 8. TRIENNIAL INTEGRITY TEST(0.1 GPM) 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 GPM) ❑ 8. DAILY VISUAL MONITORING ❑ 9. BIENNIAL INTEGRITY TEST(0.1 GPM) 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 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 ❑ b.AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM DISCONNECTION DISCONNECTION ❑ e. NO AUTO PUMP SHUT OFF ❑ c. NO AUTO PUMP SMUT OFF ❑ 11. AUTOMATIC LINE LEAK DETECTOR(3.0 GPM TEST)WITH FLOW SHUT OFF OR ❑ 11.AUTOMATIC LEAK DETECTOR RESTRICTION ❑ 12. ANNUAL INTEGRITY TEST(0.1 GPM) ❑ 12.ANNUAL INTEGRITY TEST(0.1 GPM) SUCTION/GRAVITY SYSTEM: SUCTION/GRAVITY SYSTEM: ® 13. CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS ❑ 13.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 VISUAL ALARMS ALARMS ❑ 15. AUTOMATIC LINE LEAK DETECTOR(3.0 GPM TEST)WITHOUT FLOW SHUT OFF OR ❑ 15.AUTOMATIC LINE LEAK DETECTOR(3.0 GPM TEST) RESTRICTION ❑ 18.ANNUAL INTEGRITY TEST(0.1 GPM) ❑ 18.ANNUAL INTEGRITY TEST(0.1 GPM) ❑ 17. DAILY VISUAL CHECK ❑ 17. DAILY VISUAL CHECK VIIL DISPENSER CONTAINMENT DISPENSER CONTAINMENT ❑ 1. FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE ❑ 4. DAILY VISUAL CHECK DATE INSTALLED ❑ 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 ❑ 8. NONE IX.OWNER/OPERATOR SIGNATURE I certify that the information provided herein is true and accurate to the be"f my knovAedge. SIGNATURE OF OWNER/OPERA DATE 2. 1(0. 01 NAME OF OWNER/OPERATOR(print) TITLE)F QWNEP PERAT R C. Susi Jackson ivision °Leaner, Environmental Protection Dept. Permit Number(For local use only) Perout Approved(Forlocal use only) Permit Expiration Date(Fortocal use only) CUPAFORM(4/99) Formerly SWRCB Form B