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879-D1U1 IFIED PROGRAM CONSOLIDATED FOR UNDERGROUND STORAGE TANKS - TANK PAGE 2 TANKS VI. PIPING CONSTRUCTION (Check a®thatappy) UNDERGROUND PIPING ABOVEGROUND PIPING SYSTEM TYPE ❑ 1 PRESSURE Il 2. SUCTION ❑ 3. GRAVITY ❑ 1. PRESSURE ❑ 2. SUCTION ❑ 3. GRAVITY ❑ 1. SINGLE WALL ❑ 3. LINED TRENCH ❑ 99. OTHER ❑ 1. SINGLE WALL 1195. UNKNOWN CONSTRUCTION/ MANUFACTURER ® 2. DOUBLE WALL ❑ 95. UNKNOWN ❑ 2. DOUBLE WALL : " ❑ 99. OTHER zMANUFACTURER Total Containment MANUFACTURER ❑ 1. BARE STEEL ❑ 6. FRP COMPATIBLE W/ 100% METHANOL ❑ 1. BARE STEEL ❑ 6. 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 ❑ 8. FLEXIBLE (HDPE) ❑ 99. OTHER ❑ 4. FIBERGLASS ❑ 8. CATHODIC PROTECTION ❑ S. STEEL W' COATING ❑ 9. CATHODIC PROTECTION 10 5. STEEL Al COATING ❑ 95. UNKNOWN VII. PIPING LEAK DETECTION (Check all that appy) UNDERGROUND PIPING ABOVEGROUND PIPING SINGLE WALL PIPING SINGLE WALL PIPING• PRESSURIZED PIPING (Check all that apply): PRESSURIZED PIPING (Check all that apply): - ❑ 1. ELECTRONIC UNE 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. CONVENTIONAL SUCTION SYSTEMS (Check aft that appy): . ❑ 5. DAILY VISUAL MONITORING OF PUMPING SYSTEM + TRIENNIAL PIPING INTEGRITY ❑ 5. DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM 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 appy): ❑ 9. BIENNIAL INTEGRITY TEST (0.1 GPH) ❑ a. DAILY VISUAL MONITORING ❑ 9. 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 ALARMS AND 10. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL ALARMS AND (cheek one) (Check one) ❑ a. AUTO PUMP SHUT OFF WHEN A LEAK OCCURS ❑ a. AUTO PUMP SHUT OFF WHEN A LEAK OCCURS IN b. AUTO PUMP SHUT OFF FOR LEAKS, SYSTEM FAILURE AND SYSTEM.. ❑ b. AUTO PUMP SHUT OFF FOR LEAKS, SYSTEM FAILURE AND SYSTEM DISCONNECTION DISCONNECTION ❑ C. NO AUTO PUMP SHUT OFF ❑ C. NO AUTO PUMP SHUTOFF ❑ 11. AUTOMATIC LINE LEAK DETECTOR (3.0 GPH TEST) WITH FLOW SHUT OFF 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: 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 GPH TEST) WITHOUT FLOW SHUT OFF OR ❑ 15. AUTOMATIC UNE LEAK DETECTOR (3.0 GPH TEST) RESTRICTION ❑ 16. 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 CONTAINMENT ❑ 1. FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE ❑ 4. DAILY VISUAL CHECK DATE INSTALLED Po 2. CONTINUOUS DISPENSER PAN SENSOR +AUDIBLE AND VISUAL ALARMS ❑ 5. TRENCH LINER I MONITORING 9 4 106 ❑ 3. CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR DISPENSER + AUDIBLE AND VISUAL ALARMS ❑ 6. NONE IX. OWNER/OPERATOR SIGNATURE I certify that the information provided herein is true jZd accurate to the best of my knowledge. SIGNAT 'OF OWNER.10PIONTOR DATE 2•ll,-D r NAME OF OWNERIOPERATOR (print) TITLE OF OWNER�OPERATOR C. Susi JacksonDept. Penult Number (For local use onW Permit Approved (For local use only) Permit Expiration Date (For local use only) CUPAFORM (4199) Formerly SWRCB Form 8