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PROGRAM CONSOLIDATED UNDERGROUND STORAGE TANKS - TANK PAGE 2 TANK: TA0425104 PR #: PR0234251 FAC #: FA0003508 VL YIYDVV UUiNJ I RUU I IUIN (Check all that apply) Page of SYSTEM TYPE ❑ 1. PRESSURE �&2. SUCTION ❑ 3. GRAVITY 458 CONSTRUCTION [:11. SINGLE WALL ❑3. LINED TRENCH ❑ 99. OTHER 460 2. DOUBLE WALL❑95UNKNOWN � 461MANUFACTURER A�fy� -Avimw(� ❑ 1. BARE STEEL ❑ 6. FRP COMPATIBLE w/ 100°4 METHANOL ❑ 2. STAINLESS STEEL % 7. GALVANIZED STEEL ❑ PLASTIC COMPATIBLE W/ CONTENTS ❑ 95. UNKNOWN 4. FIBERGLASS ❑ 8. FLEXIBLE (HDPE) ❑ 99. OTHER ❑ 5. STEEL W/COATING ❑ 9. CATHODIC PROTECTION 464 VII. PIPING LEAK DETECTION (Check all that apply) (A a UNDERGROUND PIPING SINGLE WALL PIPING 466 PRESSURIZED PIPING (Check all that apply): ❑ 1. ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP SHUT OFF FOR LEAK, SYSTEM FAILURE, AND SYSTEM DISCONNECTION+ AUDIBLE AND VISUAL ALARMS. ❑ 2. MONTHLY 0.2 GPH TEST ❑ 3. ANNUAL INTEGRITY TEST (0.1 GPH) CONVENTIONAL SUCTION SYSTEMS ❑ 5. DAILY VISUAL MONITORING OF PUMPING SYSTEM + TRIENNIEAL PIPING INTEGRITY TEST (0.1 GPH) SAFE SUCTION SYSTEMS (NO VALUES IN BELOW GROUNDPIPING): ❑ 7. SELF MONITORING GRAVITY FLOW ❑ 9. BIENNIAL INTEGRITY TEST (0.1) GPH SECONDARILY CONTAINED PIPING PRESSURIZED PIPING (Check all that apply): 10. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL ALARMS AND (Check arc) ❑ a. AUTO PUMP SHUT OFF WHEN A LEAK OCCURS ❑ b. AUTO PUMP SHUT OFF FOR LEAKS, SYSTEM FAILURE AND SYSTEM DISCONNECTION ❑ c. NO AUTO PUMP SHUT OFF ❑ 11. AUTOMATIC LINE LEAK DETECTOR (3.0 GPH TEST) WITH FLOW SHUT OFF OR RESTRICTION ❑ 12. ANNUAL INTEGRITY TEST (0.1 GPH) SUCTION/GRAVITY SYSTEM ❑ 13. CONTINUOUS SUMP SENSOR + AUDIBLE AND VISUAL ALARMS EMERGENCY GENERATORS ONLY (Check all that apply) ❑ 14. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF AUDIBLE AND VISUAL ALARMS ❑ 15. AUTOMATIC LINE LEAK DETECTOR (3.0 GPH TEST) WITHOUT FLOW SHUT OFF OR RESTRICTION ❑ 1. PRESSURE ❑ 2. SUCTION ❑ 3. GRAVITY 459 ❑ 1. SINGLE WALL ❑ 95. UNKNOWN 462 ❑ 2. DOUBLE WALL ❑ 99. OTHER MANUFACTURER 463 ❑ 1. BARE STEEL ❑ 6. FRP COMPATIBLE w/ 100°/ METHANOL ❑ 2. STAINLESS STEEL ❑ 7. GALVANIZED STEEL ❑ PLASTIC COMPATIBLE W/ CONTENTS ❑ 95. UNKNOWN ❑ 4. FIBERGLASS ❑ 8. FLEXIBLE (HDPE) ❑ 99. OTHER ❑ 5. STEEL W/COATING ❑ 9. CATHODIC PROTECTION 465 criptio n of the monitoring program shall be subrnitted to the local agency.) ABOVEGROUND PIPING SINGLE WALL PIPING 467 PRESSURIZED PIPING (Check all that apply): ❑ 1. ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP SHUT OFF FOR LEAK, SYSTEM FAILURE, AND SYSTEM DISCONNECTION+ AUDIBLE AND VISUAL ALARMS. ❑ 2. MONTHLY 0.2 GPH TEST ❑ 3. ANNUAL INTEGRITY TEST (0.1 GPH) ❑ 4. DAILY VISUAL CHECK CONVENTIONAL SUCTION SYSTEMS (Check all that apply) ❑ 5. DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM ❑ 6. TRIENNIAL INTEGRITY TEST (0.1 GPH) SAFE SUCTION SYSTEMS (NO VALUES IN BELOW GROUNDPIPING): ❑ 7. SELF MONITORING GRAVITY FLOW (Check all that apply): ❑ 8. DAILY VISUAL MONITORING ❑ 9. BIENNIAL INTEGRITY TEST (0.1) GPH SECONDARILY CONTAINED PIPING PRESSURIZED PIPING (Check all that apply): 10. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL ALARMS AND (Check arc) ❑ a. AUTO PUMP SHUT OFF WHEN A LEAK OCCURS ❑ b. AUTO PUMP SHUT OFF FOR LEAKS, SYSTEM FAILURE AND SYSTEM DISCONNECTION ❑ c. NO AUTO PUMP SHUT OFF ❑ 11. AUTOMATIC LEAK DETECTOR ❑ 12. ANNUAL INTEGRITY TEST (0.1 GPH) SUCTION/GRAVITY SYSTEM ❑ 13. CONTINUOUS SUMP SENSOR + AUDIBLE AND VISUAL ALARMS EMERGENCY GENERATORS ON LY (Cha,k all that apply) ❑ 14. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF AUDIBLE AND VISUAL ALARMS ❑ 15. AUTOMATIC LINE LEAK DETECTOR (3.0 GPH TEST) WITHOUT FLOW SHUT OFF OR 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 468 ❑ 2. CONTINUOUS DISPENSER PAN SENSOR + AUDIBLE AND VISUAL ALARMS ❑ 5. TRENCH LINER / MONITORING ❑ 3. CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR A6. NONE DISPENSER +AUDIBLE AND VISUAL ALARMS 469 IX. OWNER/OPERATOR SIGNATURE I certify that the information provided herein is true and accurate to the bat of my knowledge. SIGNATURE OF E OPERATOR DATE 470 Jq i 1111.3 NAME OF O TOR (p t) %TITLE OF OWNER/OPERATOR 471 (� Y- 472 htN;-]T10003365 mber(Forlocaluseonly) 473 Penmt Approved (For localuse ady) 474 r Permit Expiration Date (For local use only) 475 EE0003804 1/1/1993 UPCF (12/99 revised)