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IFIED PROGRAM CONSOLIDATED FO TANKS UNDERGROUND STORAGE TANKS - TANK PAGE 2 VI. PIPING CONSTRUCTION (Check ail that apply) UNDERGROUND PIPING ND_PIPING _ SYSTEM TYPE/ tA 1. PRESSURE 112. SUCTION 113. GRAVITY v i Y ❑ 1. PRESSURE ❑ 2. UCTION ❑ 3. GRAVIT�S ❑ 1. SINGLE WALL ❑ 3. LINED TRENCH ❑ 99. OTHER � ❑ 1, SINGLE WALL ❑ 95. UNKNOWN J / 1 CONSTRUCTION/ MANUFACTURER M 2. DOUBLE WALL ❑,95 UNKNOWI4 % 2. DOUBLE WALL Q 9, TTHER MANUFACTURER 1ti1 . �A g 1 6.er G IUs C MANUFACTURER V �-IJIrS, �St ❑ 1. BARE STEEL ❑ 8. FRP COMPATIBLE W1 100% METHANOL ❑ 1. BARE STEEL ❑ 8. FRP COMPATIBLE W/ 100% METRA 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 ❑ B. FLEXIBLE (HOPE) - ❑ 99. ER ` ❑ 4. FIBERGLASS ❑ 8. FLEXIBLE (HOPE) ❑ 99. OTHER ❑ 4. FIBERGLASS ❑ 9. CATHODIC PROTECTION 5. STEEL W/ COATING ❑ 9. CATHODIC PROTECTION 195. STEEL WI COATING ❑ 95. UNKNOWN Vlf. 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 11 2, MONTHLY 0.2 GPM TEST , 112. 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 all that apply): ❑ 5. DAILY VISUAL MONITORING OF PUMPING SYSTEM + TRIENNIAL PIPING INTEGRITY ❑ S. 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 alf that appy): ❑ 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 appy): 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 9Lb. AUTO PUMP SHUT OFF FOR LEAKS, SYSTEM FAILURE AND SYSTEM DISCONNECTION DISCONNECTION ❑ c. NO AUTO PUMP SHUT OFF ❑ c. NO AUTO PUMP SHUT OFF PO 11 AUTOMATIC LINE LEAK DETECTOR (3.O GPH 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 ea 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 VIII. DISPENSER CONTAINMENT DISPENSER CONTAINMENT ❑ 1. FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE ❑ 4. DAILY VISUAL CHECK DATEINS 112. CONTINUOUS DISPENSER PAN SENSOR + AUDIBLE AND VISUAL ALARMS ❑ 5. TRENCH LINER/ MONITORING 4LLED ��((�� 3. CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR DISPENSER + AUDIBLE AND VISUAL ALARMS ❑ 8. NONE IX. OWNER/OPERATOR SIGNATURE I ceruty that the information proed herein is true and accurate to the best of my knowledge. SIGNATURE R DATE p 8 NAME OF ONANER/OPERATORt 0 1hVc> 'Y' `MI TITL ER OPSRA R p M i�Y e e + � Permit Number (For local use only) Permit Approved (For local use only) PennA Expiration Date (Fork eel use only) CUPAFORM (4/99) is • Formerly SWRCB Form B V1