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IFIED PROGRAM CONSOLIDATED FO 1.[al►lli�] Vi. PIPING CONSTRUCTION (Check a9 that appy) UNDERGROUND PIPING ABOVEGROUND PIPING SYSTEM TYPE 1. PRESSURE ❑ 2. SUCTION ❑ 3. GRAVITY 191. PRESSURE ❑ 2. SUCTION ❑ 3. GRAVITY ❑ 1. SINGLE WALL ❑ 3. LINED TRENCH ❑ 99. OTHER ❑ I. SINGLE WALL 95. UNKNOWN CONSTRUCTION/ MANUFACTURER It 2, DOUBLE WALL ❑®9_5. UNKNg?% �❑ 2. DOUBLE WALL �.,t<.+9 9� OTHER MANUFACTURER Yrl ®w P \ �i,I� eJ MANUFACTURERi ❑ 1. BARE STEEL ❑ 8. IMP COMPATIBLE WI 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 ❑ 8. FLEXIBLE (HDPE) ❑ 99. OTHER ❑ 4. FIBERGLASS ❑ 9. CATHODIC PROTECTION 5. STEEL W/ COATING ❑ 9. CATHODIC PROTECTION a 05. STEEL Al COATING ❑ 95. UNKNOWN VII. PIPING LEAK DETECTION (Check a8 that apply) UNDERGROUND PIPING ABOVEGROUND PIPING SINGLE WALL PIPING SINGLE WALL PIPING - PRESSURIZED PIPING (Check as that appy). PRESSURIZED PIPING (Check all that apply): ❑ 1. ELECTRONIC LINE 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 all that apply): ❑ 5. DAILY VISUAL MONITORING OF PUMPING SYSTEM + TRIENNIAL PIPING INTEGRITY ❑ 5. DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM TEST (0.1 GPH) ❑ 8. 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 as that appy): ❑ 9. BIENNIAL INTEGRITY TEST (0.1 GPH) ❑ 9. DAILY VISUAL MONITORING ❑ 9. BIENNIAL INTEGRITY TEST (0.1 GPH) SECONDARILY CONTAINED PIPING PRESSURIZED PIPING (Check alt that apply): SECONDARILY CONTAINED PIPING PRESSURIZED PIPING (Checka#that apply): - 10. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL ALARMS AND (Check one) 10. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL ALARMS AND (check one) ❑ a. AUTO PUMP SHUT OFF WHEN A LEAK OCCURS ❑ a. AUTO PUMP SHUT OFF WHEN A LEAK OCCURS Lpb AUTO PUMP SHUT OFF FOR LEAKS, SYSTEM FAILURE AND SYSTEM DISCONNECTION b. AUTO PUMP SHUT OFF FOR LEAKS, SYSTEM FAILURE AND SYSTEM DISCONNECTION ❑ c. NO AUTO PUMP SHUT OFF ❑ c. NO AUTO PUMP SHUT OFF N11. 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 as that apply) EMERGENCY GENERATORS ONLY (Check as 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 LINE LEAK DETECTOR (3.0 GPH TEST) RESTRICTION ❑ 18. ANNUAL INTEGRITY TEST (0.1 GPH) ❑ 18. ANNUAL INTEGRITY TEST (0.1 GPH) ❑ 17. DAILY VISUAL CHECK ❑ 17. DAILY VISUAL CHECK Vill. DISPENSER CONTAINMENT DISPENSER CONTAINMENT ❑ 1. FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE ❑ 4. DAILY VISUAL CHECK DATE IN LLED ❑ 2. CONTINUOUS DISPENSER PAN SENSOR + AUDIBLE AND VISUAL ALARMS ❑ 5. TRENCH LINER/ MONITORING "'1f C7 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 rate to the Hest of my knowledge. SIGNATURE OF OWNER/OPERA T DATE ® ® NAME. OF OWNER/OPERATOR (prf t TITLE OF OWNER,OPERATO ° U i Permit Number (For local use only) Permit Approved (For local use only)I Permit Expiration Date lFor local use onlv) CUPAFORM (4/99) Formerly SWRCB Form B