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v111411rtaw Qu rvnm 4Page,_,�& UNDER�UND STORAGE TANKS -UK PAGE 2\f l:PIPING CONSTRUCTION(Check all that apply) UNDERGROUND PIPING ABOVEGROUND PIPING SYSTEM TYPE ®1.PRESSURE ❑2.SUCTION ❑3.GRAVITY 456 ❑1.PRESSURE ❑2. SUCTION ❑3.GRAVITY 459 CONSTRUCTION/ ❑1.SINGLE WALL [:13.LINED TRENCH ❑99.OTHER 460 ❑1.SINGLE WALL ❑95.UNKNOWN ase MANUFACTURER ®2.DOUBLE WALL ❑95.UNKNOWN ❑2.DOUBLE WALL ❑99.OTHER MANUFACTURER AO Smltll 461 MANUFACTURER 463 ❑1.BARE STEEL ®6.FRP COMPATIBLE w/100% METHANOL ❑1.BARE STEEL [16.FRP COMPATIBLE W1100i METHANOL ❑2.STAINLESS STEEL [17.GALVANIZED STEEL ❑UKNOWN ❑2. STAINLESS STEEL [17.GALVANIZED STEEL ❑3.PLASTIC COMPATIBLE W/CONTENTS ❑99. OTHER ❑3. PLASTIC COMPATIBLE W/CONTENTS ❑8.FLEXIBLE(HDPE) ❑99. OTHER ❑4.FIBERGLASS ❑8.FLEXIBLE(HDPE) [14. FIBERGLASS ❑9.CATHODIC PROTECTION ❑5.STEEL W/COATING ❑9.CATHODIC PROTECTION 464 ❑5. STEEL W/COATING ❑95.UNKNOWN 465 VII.PIPINGLEAK`DETECTION Check all that apply) A des cri tioniof the monitoring ram shall be submitted 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 [11. ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP SHUT OFF FOR LEAK,SYSTEM FAILURE,AND SYSTEM DISCONNECTION+AUDIBLE AND VISUAL LEAK,SYSTEM FAILURE,AND SYSTEM DISCONNECTION+ AUDIBLE AND VISUAL ALARMS. ALARMS. ❑2. MONTHLY 0.2 GPH TEST [12. MONTHLY 0.2 GPH TEST [13. ANNUAL INTEGRITY TEST(0.1GPH) [13. ANNUAL INTEGRITY TEST(0.1GPH) ❑4. DAILY VISUAL CHECK CONVENTIONAL SUCTION SYSTEMS CONVENTIONAL SUCTION SYSTEMS(Check all that appy) [15. DAILY VISUAL MONITORING OF PUMPING SYSTEM+TRIENNIAL PIPING INTEGRITY [15. DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM TEST(0.1 GPH) SAFE SUCTION SYSTEMS(NO VALUES IN BELOW GROUNDPIPING): [16. TRIENNIAL INTEGRITY TEST(0.1 GPH) ❑7. SELF MONITORING SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): GRAVITY FLOW ❑7. SELF MONITORING [19. BIENNIAL INTEGRITY TEST(0.1 GPH) GRAVITY FLOW(Check all that appy): [18. DAILY VISUAL MONITORING [19. 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 (Check one) (Check one) ❑a. AUTO PUMP SHUT OFF WHEN A LEAK OCCURS ❑a AUTO PUMP SHUT OFF WHEN A LEAK OCCURS Ob. 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 SHUT OFF ®11. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)WITH FLOW 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 [313. CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS E:113. 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 [114. 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 ❑16. ANNUAL INTEGRITY TEST(0.1 GPH) ❑16. ANNUAL INTEGRITY TEST(0.1 GPH) [117. DAILY VISUAL CHECK ❑17. DAILY VISUAL CHECK VIII.QISPENSER CONTAINMENT DISPENSER 01. FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE [14.DAILY VISUAL CHECK CONTAINMENT DATE INSTALLED 468 ❑2. CONTINUOUS DISPENSER PAN SENSOR+AUDIBLE AND VISUAL ALARMS ❑5.TRENCH LINER/MONITORING 1996 ❑3. CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR DISPENSER+ ❑6.NONE 469 AUDIBLE AND VISUAL ALARMS IX,OWNERIOPERATOR SIGNATURE I certify that the information provided herein is true and accurate to the best of my knowledge. SIGNATURE OF OW NER/OPERAT DATE 470 NAME OF OWNER/OPRATOR(print) UTITLE OF OWNER/OPERATOR 472 Sandy Huff Operations & Environmental Specialist Permit Number(For local use only) 473 Permit Approved(For local use only) Permit Expiration Date(For local use only) 475 UPCF(1/99 revised) Formerly SWRCB Form B