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- V1141r IJ rKVIaKAM UVIN501,11)ATED YIORM �Tg� �Tg� �j TANKS UNDERGROUND STORAGE TANKS - TANK PAGE 2 VI. PIPING CONSTRUCTION (Check all that apply) UNDERGROUND PIPING ABOVEGROUND PIPING SYSTEM TYPE 1. PRESSURE ❑ 2. SUCTION ❑ 3. GRAVITY 458 Cl I. PRESSURE ❑ 2. SUCTION ❑ 3. GRAVITY 459 CONSTRUCTION ❑ 1. SINGLE WALL ❑ 3. LINED TRENCH ❑ 99. OTHER 460 ❑ 1. SINGLE WALL ❑ 95. UNKNOWN MANUFACTURER ;g 2. DOUBLE WALL ❑ 95. UNKNOWN 462 ❑ 2. DOUBLE WALL ❑ 99. OTHER MANUFACTURER , , , _ , 461 MANUFACTURER, , , _ 463 ❑ 1. BARE STEEL ❑ 6. FRP COMPATIBLE w/I00% METHANOL , ❑ 1. BARE STEEL ❑ G. FRI COMPATIBLE w/tool METI3ANOL ❑ 2. STAINLESS STEEL p 7. GALVANIZED STEEL ❑ Unknown ❑ 2. STAINLESS STEEL ❑ 7. GALVANIZED STEEL ❑ 3. PLASTIC COMPATIBLE W/ CONTENTS ❑ 99. Other ❑ 3. PLASTIC COMPATIBLE W/ CONTENTS ❑ 8, FLEXIBLE (I IDPE) ❑ 99. OTHER ja4. FIBERGLASS ❑ 8. FLEXIBLE (HDPE) 4. FIBERGLASS ❑ ❑ 9. CATHODIC PROTECTION ❑ 5. STEEL W/COATING ❑ 9. CATHODIC PROTECTION 464 ❑ 5. STEEL W/COATING ❑ 95. UNKNOWN 465 VII. PI PING LEAK DETECTION (Check all that apply) (A description of the monitoring program shall be submitted to the local agency.) UNDERGROUND PIPING AI30VIiGItOUND 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 ❑ I. ELECTRONIC LINE LEAK DETECTOR 3.0 GPH I -EST Will I AUTO PUMP OFF FOR LEAK, SYSTEM FAILURE, AND SYSTEM DISCONNECTION + AUDIBLE AND VISUAL ALARMS. SHUT OFF FOR LEAK, SYSTEM FAILURE, AND SYSTEM DISCONNECTION + ❑ 2. MONTHLY 0.2 GPH TEST AUDIBLE AND VISUAL ALARMS. ❑ 2. MONTHLY 0.2 GPH TEST ❑ 3. ANNUAL INTEGRITY TEST (0.)GPH) ❑ 3. ANNUAL INTEGRITY TEST (0.1GPH) ❑ 4. DAILY VISUAL CHECK CONVENTIONAL SUCTION SYSTEMS CONVENTIONAL SUCTION SYSTEMS (Check all that apply) ❑ 5. DAILY VISUAL MONITORING OF PUMPING SYSTEM + TRIENNIAL PIPING INTEGRITY TEST (0.1 GPH) ❑ 5. DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM SAFE SUCTION SYSTEMS (NO VALUES IN BELOW GROUNDPIPING): ❑ 6. TRIENNIAL INTEGRITY TEST (0.1 GYN) ❑ 7. SELF MONITORING SAFE SUCTION SYSTEMS (NO VALVES IN BELOW GROUND PIPING): GRAVITY FLOW ❑ 7. SELF MONITORING ❑ 9. BIENNIAL INTEGRITY TEST (0.1 GPH) GRAVITY FLOW (Check all that apply): ❑ 8. 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 (Check one) 10. CONTINUOUS TURBINE SUMP SENSOR WITIi AUDIBLE AND VISUAL ALARMS AND (Check one) ❑ a. AUTO PUMP SHUT OFF WHEN A LEAK OCCURS ❑ a AUTO PUMP SHUT OFF W1 LEN A LEAK OCCURS ❑ b. AUTO PUMP SHUT OFF FOR LEAKS, SYSTEM FAILURE AND SYSTEM Cl b AUTO PUMP SHUT OFF FOR LEAKS, SYSTEM FAILURE AND SYSTEM DISCONNECTION DISCONNECTION ❑c. NO AUTO PUMP SHUT OFF Pit 11. AUTOMATIC LINE LEAK DETECTOR (3.0 GPH TEST) WITII FLOW SHUT ❑c NO AUTO PUMP SHUT OFF OFF OR RESTRICTION ❑ 11. AUTOMATIC LEAK DETECTOR ❑ 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 " p 13. CONTINUOUS SUMP SENSOR 4 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 VISUAL ALARMS ❑ 14. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF ❑ 15. AUTOMATIC LINE LEAK DETECTOR (3.0 GPH TEST) WITIIOUT FLOW AUDIBLE AND VISUAL. ALARMS SHUT OFF OR RESTRICTION Cl 15. AUTOMATIC LINE LEAK DETECTOR (3.0 Gill I TEST) Cl 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 Z 1. FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE ❑ 4. DAILY VISUAL CHUCK DATEINSTALLED 468 ❑ 2. CONTINUOUS DISPENSER PAN SENSOR + AUDIBLE AND VISUAL ALARMS ❑ 5. TRENCH LINER / MONITORING �j It �� ❑ 3. CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR DISPENSER + AUDIBLE AND VISUAL ALARMS ❑ G. NONE 469 IX. OWNER/OPERATOR SIGNATURE 1 certify that the information provided herein is true and accurate to the best of my knowledge. SIGNATURE OF OWNER/OPERATOR DATE 470 NAME OF OWNER/OPRATOR (Print) TITLE OF OWNER/OPEKATOR 472 Permit Number (For local use only) 473 Permit Approved (For local use only) Permit Expiration Date (For local use only) 475 rr ur ",1- (1 » fevISCU) - 12 Formerly SWRCB Form B