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Home My WebLink AboutUNDERGROUND TANK ""ro,,_···.··.·...··..·IUI··· 1IiŒ............. L Ii""··t: " ,& Î þ .. ¡GROUP INC. :.~~ :!' ~. . ARCHITECTURE. ENGINEERING. ENVIRONMENTAL SERVICES 1137 North McDowell Blvd., Petaluma, CA 94954-1110 Telephone: (707) 765-1660 Facsimile: (707) 765-9908 John W. Johnson, Architect Established 1966 LETTER OF TRANSMITTAL Date To: From: RE: May 21, 2002 Job # 9365.50 Steve Underwood Bakersfield Fire Department Office of Environmental Services 1715 Chester Ave. Suite 300 Bakersfield, CA 93301 (661) 326-3190 Robert M. Forloine RHL Design Group, Inc. Food 4 Less Fuel Center 1101 Union Avenue Bakersfield, CA 93307 TRA~SMITTED: VIA: CalifOl:l1i:¡Overlligh! DFoJ' ,aþproval. D:¡:;oryoLJIuse 0 A~requested ¡g¡ Foneviewandcomment D~etLJJ'n o Other:. .QTY. 2 1 1 2 1 1 -,-'-', DATËC OS/21/02 OS/21/02 OS/21/02 OS/21/02 OS/21/02 OS/21/02 REV.; DËSCRIPTÎÒN 2 Sets of Tank Drawings (24x36) Check for $1,300.00 Application Tank "A" & "B" Forms Contractors License and Liability Forms Contractors Safet Manual REMARKS: If you have any questions please feel free to call me at (707) 765-1660 Ext. 234 SIGNED: XlJ- ß· ~ Robert M. Forloine / Job Captain IF ENCLOSURES ARE NOT AS NOTED, KINDLY NOTIFY US! THANK YOU BELLE VUE, WA LA HABRA, CA MARTINEZ, CA PET ALUM A, CA SACRAMENTO, CA SCOTTSDALE, AZ VANCOUVER, WA \\PET A\SYS\PROJECTI9k\9k.5\9365,5O\DOCS\05-21 ~2 9365.50 Steve Underwood Trans.doc ì'" ' ~\ ~ . . e TTNTFTRTI PRO(;RAM C.ONSOTJTIATRTI FORM TANKS UNDERGROUND STORAGE TANKS - FACILITY TYPE OF ACTION þi I. NEW SITE PERMIT (Check one item only) o 3. RENEWAL PERMIT o 4. AMENDED PERMIT o 5.CHANGE OF INFORMATION specifY change local use only o 6.TEMPORARY SITE CLOSURE (one page per site) Page _ of _ o 7 .PERMANENTLY CLOSED SITE o 8. TANK REMOVED 400 I. FACILITY / SITE INFORMATION 401 BUSINESS NAME (Same as FACIUTY NAME or DBA -Doing Business As) L~ NEAREST CROSS STREET FACILITY ID# BUSINESS 0 L GAS STATION 03. FARM 5. COMMERCIAL TYPE 0 2. DISTRffiUTOR 0 4. PROCESSOR 0 6. OTHER 403 402 TOTAL NUMBER OF TANKS Is facility on Indian Reservation or "If owner ofUST is a public agency: name of supervisor of division, section or office which REMAINING AT SITE trustlands? operates the UST (This is the contact person for the tank records.) 404 0 Yes ]Z( No 405 406 II. PROPERTY OWNER INFORMATION 407 PHONE ~\ ")393 -7000 408 9 q ï>r()?~r+¡~s L? 409 410 STATE 411 ZIP CODE CA. 93380 04. LOCAL AGENCY /DISTRICT 06. STATE AGENCY 05. COUNTY AGENCY 07. FEDERAL AGENCY 412 o L CORPORATION 02. INDIVIDUAL 3. PARTNERSHIP 413 Ill. TANK OWNER INFORMATION 414 415 000 416 417 419 L CORPORATION 02. INDIVIDUAL 04. LOCAL AGENCY / DISTRICT o 3. PARTNERSHIP 05. COUNTY AGENCY 420 IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER 421 V. PETROLEUM UST FINANCIAL RESPONSffiILITY INDICATE METHOD(s) Ø"L SELF-INSURED o 2. GUARANTEE o 3. INSURANCE 04. SURETY BOND 07. STATE FUND 05. LETTER OF CREDIT 08. STATE FUND & CFO LETTER 06. EXEMPTION 09. STATEFUND&CD o 10. LOCAL GOVT MECHANISM o 99. OTHER: 422 VI. LEGAL NOTIFICATION AND MAILING ADDRESS Check one box to indicate which address should be used for legal notifications and mailing. Legal notifications and mailings will be sent to the tank owner unless box I or 2 is checked. o 1. FACILITY 02. PROPERTY OWNER Jilf3'. TANK OWNER 423 VII. APPLICANT SIGNATURE Certification - I certilÿ that the information provided herein is Inle and accurate to the best of my knowledge. 426 DATE / S;~II~ TITLE OF APPLICANT Arck' 424 425 427 / 428 429 UPCF (1/99 revised) 8 Formerly SWRCB Form A -- . ! e UNIFIED PROGRAM CONSOLIDATED FORM TANKS e UNDERGROUND STORAGE TANKS - TANK PAGE 1 (two pages per tank) Page_of _ TYPE OF ACTION þ{ I NEW SITE PERMIT 0 4 AMENDED PERMIT 0 5 CHANGE OF INFORMATION 0 6 TEMPORARY SITE CLOSURE (Check one item only) 0 7 PERMANENTLY CLOSED ON SITE o 3 RENEWAL PERMIT (Specify reason - for local use only) (Specify reason - for local use only) 0 8 TANK REMOVED 430 FACILITY ID: I 431 I, TANK DESCRIPTION (A scaled plot plan with the location of the UST system including buildings and landmarks shall be submitted to the local agency.) TANK ID # 432 TANK MANUFACTURER 433 COMPARTMENTALIZED TANK Yes, D No 434 OTHER CORROSION 0 I MANUFACTURED CATHODIC PROTECTION IF APPLICABLE PROTECTION (Check one item only) 0 2 SACRIFICIAL ANODE SPILL AND OVERFILL YEAR INSTALLED r ß I 450 (Check all that apply) 0 I SPILL CONTAINMENT Jil'2DROPTUBE 3' STRIKER PLATE IV. TANK LEAK DETECTION (A description of the monitoring program shall be submitted to the local agency.) IF SINGLE WALL TANK (Check all that apply) 453 IF DOUBLE W ALL TANK OR TANK WITH BLADDER 454 (Check one item only) 01 VISUAL (EXPOSED PORTION ONLY) 05 MANUAL TANK GAUGING (MTG) 01 VISUAL (SINGLE WALL IN VAULT ONLY) o 2 AUTOMATIC TANK GAUGING (ATG) 0 6 VADOSE ZONE þ!( 2 CONTINUOUS INTERSTITIAL MONITORING o 3 CONTINUOUS ATG 0 7 GROUNDWATER 0 3 MANUAL MONITORING 04 STATISTiCAL INVENTORY RECONCILIATION 08 TANK TESTING (SIR) BIENNIAL TANK TESTING D 99 OTHER IV. TANK CLOSURE INFORMATION I PERMANENT CLOSURE IN PLACE II. TANK CONTENTS TANK USE 439 lit I. MOTOR VEHICLE FUEL (If marked complete Petroleum Type) o 2. NON-FUEL PETROLEUM o 3. CHEMICAL PRODUCT 04. HAZARDOUS WASTE (Includes Used Oil) 095. UNKNOWN PETROLEUM TYPE )(1.. REGULAR UNLEADED 'ß,I b. PREMIUM UNLEADED Ole. MIDGRADE UNLEADED o 2. LEADED o 3. DIESEL o 4. GASOHOL COMMON NAME (from Hazardous Materials inventory page) III, TANK CONSTRUCTION TYPE OF TANK (Check one item only) 3. SINGLE WALL WITH EXTERiOR MEMBRANE LINER 04. SIGNLE WALL IN VAULT 3. FIBERGLASS I PLASTIC 04. STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC (FRP) I. BARE STEEL 3. FIBERGLASS I PLASTIC . 0 2. STAINLE~S STEEL 04. STEEL CLAD .w/FIBERGLASS REINFORCED PLASTIC (FRP) o 5. CONCRETE 3. EPOXY LINING 0 5. GLASS LINING o 4 PHENOLIC LINING ~ 6 UNLINED 1. SINGLE WALL TANK MATERIAL -primary tank 1i12. DOUBLE WALL 1. BARE STEEL []2. STAINLESS STEEL (Check one item only) TANK MATERIAL - secondary tank (Check one item only) TANK INTERIOR LINING o 1. RUBBER LINED OR COATING (Check one item only) [] 2 ALKYD LINING ¿. If "Yes", oomplete one page for eacb compartment. 436 NUMBER OF COMPARTMENTS '2- 437 438 440 o 5. JET FUEL 06. AVIATION FUEL [] 99. OTHER 441 CAS# (ftoni Hazardous Materials Inventory page) 442 5. SINGLE WALL WITH INTERNAL BLADDER SYSTEM [] 95. UNKNOWN 099. OTHER 5. CONCRETE 95. UNKNOWN [] 8. FRP COMPTIBLE WIlOO% METHANOL [] 99. OTHER 443 444 5. CONCRETE 95. UNKNOWN 08. FRP COMPTIBLE W/IOO% METHANOL 099. OTHER 010. COATED STEEL 445 95. UNKNOWN [] .99 OTHER 446 DATE INSTALLED 447 (For local use only) o 95 UNKNOWN o 99 OTHER 448 449 DATE INSTALLED o 3 FIBERGLASS REINFORCED PLASTIC o 4 IMPRESSED CURRENT (For local use only) TYPE (local use only) 451 OVERFILL PROTECTION EQUIPMENT:YEAR INSTALLED ,Tß/ ~ I ALARM 03 FILL TUBE SHUT OFF VALVE þ!{ 2 BALL FLOAT 0 4 EXEMPT ESTIMATED DATE LAST USED (YR/MOIDAY) 455 ESTIMATED QUANTITY OF SUBSTANCE REMAINING gallons TANK FILLED WITH INERT MATERIAL? DVes D No UPCF (12/99 revised) 10 452 456 457 Fonnerly SWRCB Fonn B .. ~ e e UNIFIED PROGRAM CONSOLIDATED FORM TANKS UNDERGROUNDSTORAGETANKS-TANKPAGE2 VI. PIPING CONSTRUCTION ICheekall that annlv) Page of UNDERGROUND PIPING ABOVEGROUND PIPING SYSTEM TYPE tii! L PRESSURE D 2. SUCTION D 3. GRAVITY 458 D L PRESSURE D 2. SUCTION D 3. GRAVITY 459 CONSTRUCTION D L SINGLE WALL D 3. LINED TRENCH D 99. OTHER 460 D L SINGLE WALL D 95. UNKNOWN 462 MANUFACTURER þ/l2. DOUBLE WALL D 95. UNKNOWN D 2. DOUBLE WALL D 99. OTHER MANUFACTURER €n'~:--- 461 MANUFACTURER 463 D L BARE STEEL D 6. FRP COMPATffiLE w/IOO% METHANOL D I. BARE STEEL D 6. FRPCOMPATIBLE WIlOO%METHANOL D 2. STAINLESS STEEL D 7. GALVANIZED STEEL D Unknown D 2. STAINLESS STEEL D 7. GALVANIZED STEEL D 3. PLASTIC COMPATIBLE W/ CONTENTS :2(99. Other D 3. PLASTIC COMPATIBLE W/ CONTENTS D 8. FLEXIBLE (HOPE) D 99. OTHER D 4. FIBERGLASS D 8. FLEXIBLE (HOPE)POV F/tfOre D 4. FIBERGLASS D 9. CATHODIC PROTECTION D 5. STEEL W/COATING D 9. CATHODIC PROTECTION 464 D 5. STEEL W/COATING D 95. UNKNOWN 465 VII. PIPING LEAK DETECTION ICheek all that annlv) I A deseriotion of the monitorin. nrn= shall be submitted to the local ..enev.) .. UNDERGROUND PIPING ABOVEGROUND PIPING SINGLE WALL PIPING 466 SINGLE WALL PIPING 467 PRESSURIZED PIPING (Check all that apply): PRESSURIZED PIPING (Check all that apply): D I. ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP SHUT D I. ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP OFF FOR LEAK, SYSTEM FAILURE, AND SYSTEM DISCONNECTION + SHUT OFF FOR LEAK, SYSTEM FAILURE, AND SYSTEM DISCONNECTION + AUDIBLE AND VISUAL ALARMS. AUDIBLE AND VISUAL ALARMS. D 2. MONTHLY 0.2 GPH TEST D 2. MONTHLY 0.2 GPH TEST D 3. ANNUAL INTEGRITY TEST (0. I GPH) D 3. ANNUAL INTEGRITY TEST (0. I GPH) D 4. DAILY VISUAL CHECK CONVENTIONAL SUCTION SYSTEMS CONVENTIONAL SUCTION SYSTEMS (Check all that apply) D 5. DAILY VISUAL MONITORING OF PUMPING SYSTEM + TRIENNIAL PIPING D 5. DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM INTEGRITY TEST (0.1 GPH) SAFE SUCTION SYSTEMS (NO VALUES IN BELOW GROUNDPIPING): D 6. TRIENNIAL INTEGRITY TEST (0.1 GPH) D 7. SELF MONITORING SAFE SUCTION SYSTEMS (NO VALVES IN BELOW GROUND PIPING): GRAVITY FLOW D 7. SELF MONITORING D 9. BIENNIAL INTEGRITY TEST (0.1 GPH) 7AßrI?'" s tßr GRAVITY FLOW (Check all that apply): "" Vt!.t!.dsr ~"ðl é/~/ron¡c D 8. DAILY VISUAL MONITORING :/Þ t;t/ P/1°o - 001 D 9. BIENNIAL INTEGRITY TEST (0.1 GPH) SECONDARILY CONTAINED PIPING SECONDARILY CONTAINED PIPING PRESSURIZED PIPING (Check all th.t apply): PRESSURIZED PIPING (Check all that apply): 10. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL 10. CONTINUOUS TURBINE SUMP SENSOR WITH AUDffiLE AND VISUAL ALARMS AND (Check one) ALARMS AND (Check one) D a. AUTO PUMP SHUT OFF WHEN A LEAK OCCURS D a AUTO PUMP SHUT OFF WHEN A LEAK OCCURS D b. AUTO PUMP SHUT OFF FOR LEAKS, SYSTEM FAILURE AND SYSTEM D b AUTO PUMP SHUT OFF FOR LEAKS, SYSTEM FAILURE AND SYSTEM DISCONNECTION DISCONNECTION Ere. NO AUTO PUMP SHUT OFF De NO AUTO PUMP SHUT OFF _II. AUTOMATIC LINE LEAK DETECTOR (3.0 GPH TEST) WITH FLOW SHUT D I L AUTOMATIC LEAK DETECTOR OFF OR RESTRICTION D 12. ANNUAL INTEGRITY TEST (0.1 GPH) D 12. ANNUAL INTEGRITY TEST (0.1 GPH) SUCTION/GRAVITY SYSTEM SUCTION/GRAVITY SYSTEM D 13. CONTINUOUS SUMP SENSOR + AUDIBLE AND VISUAL ALARMS D 13. CONTINUOUS SUMP SENSOR + AUDIBLE AND VISUAL ALARMS EMERGENCY GENERATORS ONLY (Check all that apply) EMERGENCY GENERATORS ONLY (Check all that apply) D 14. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF · D 14. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF · AUDIBLE AND VISUAL ALARMS AUDIBLE AND VISUAL ALARMS D 15. AUTOMATIC LINE LEAK DETECTOR (3.0 GPH TEST) WITHOUT FLOW D IS. AUTOMATIC LINE LEAK DETECTOR (3.0 GPH TEST) SHUT OFF OR RESTRICTION D 16. ANNUAL INTEGRITY TEST (0.1 GPH) D 16. ANNUAL INTEGRITY TEST (0.1 GPH) D 17. DAILY VISUAL CHECK D 17. DAILY VISUAL CHECK VIII, DISPENSER CONTAINMENT DISPENSER CONTAINMENT D L FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE D 4. DAILY VISUAL CHECK DATE INSTALLED 468 ,,!g2. CONTINUOUS DISPENSER PAN SENSOR + AUDIBLE AND VISUAL ALARMS D 5. TRENCH LINER / MONITORING D 3. CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR D 6. NONE 469 DISPENSER + AUDIBLE AND VISUAL ALARMS IX. OWNER/OPERATOR SIGNATURE I certify that the information provided herein is tru~ccurate to the best of my knowledge. SIGNATURE OF O~ ~O~ DATE 51¡'J/t!/~ 470 NAM}öJìN( 1 R (p~t) 471 TITLE OF OWNER/OPERATOR 472 -/ ~~ C.P.O. 1// '//'rr- L Pennit Nwnber (For lòuI' use only) 473 Pennit Approved (For local use only) 474 Pennit Expiration Date (For local use only) 475 UPCF (12/99 revised) 12 Formerly SWRCB Form B ~ e - .' UNIFIED PROGRAM CONSOLIDATED FORM TANKS UNDERGROUND STORAGE TANKS -TANK PAGE 1 (two pages per tank) Pago_of _ TYPE OF ACTION ~ I NEW SITE PERMIT (Check 0"" item only) BUSINESS NAME (Same as FAaLITY NAME or DBA - Doiog Business AJJ) Ft. FACILITY ID: o 6 TEMPORARY SITE CLOSURE o 7 PERMANENTLY CLOSED ON SITE o 8 TANK REMOVED 430 I o 4 AMENDED PERMIT 0 5 CHANGE OF INFORMATION o 3 RENEWAL PERMIT (Specify reason - for local use only) (Specify reason - for local use only) 431 I, TANK DESCRIPTION (A scaled plot plan with the location of the UST system including buildings and landmarks shall be submitted to the local agency.) TANK ID # 432 TANK MANUFACTURER 433 COMPARTMENTALIZED TANK Yes D No 434 G. Ifuycs", oomp1ete one page for each compartment 436 NUMBER OF COMPARTMENTS '2-- 437 438 n. TANK CONTENTS TANK USE 439 tilt L MOTOR VEIDCLE FUEL (lfmarked complete Petroleum Type) o 2. NON-FUEL PETROLEUM o 3. CHEMICAL PRODUCT o 4. HAZARDOUS WASTE (Includes Used Oil) o 95. UNKNOWN PETROLEUM TYPE o la. REGULAR UNLEADED 1iJ.I b. PREMIUM UNLEADED Ole. MIDGRADE UNLEADED 440 o 2. LEADED o 3. DIESEL 04. GASOHOL o 5. JET FUEL 06. AVIATION FUEL o 99. OTHER 441 CAS# (from Hazardous Materials Inventory page) 442 COMMON NAME (from Hazardous Materials Inventory page) TYPE OF TANK (check one item only) L SINGLE WALL m. TANK CONSTRUCTION 3. SINGLE WALL WITH 5. SINGLE WALL WITH INTERNAL BLADDER SYSTEM EXTERIOR MEMBRANE LINER 0 95. UNKNOWN 04. SIGNLEWALLIN VAULT 099. OTHER 3. FIBERGLASS I PLASTIC 5. CONCRETE 95. UNKNOWN 04. STEEL CLAD WIFIBERGLASS 08. FRP COMPTffiLE W/IOO% METHANOL 099. OTHER REINFORCED PLASTIC (FRP) 3. FIBERGLASS I PLASTIC o 4. STEEL CLAD WlFffiERGLASS REINFORCED PLASTIC (FRP) o 5. CONCRETE 3. EPOXY LINING 443 tit 2. DOUBLE WALL TANK MATERIAL - primary tank L BARE STEEL (Check one item only) 0 2. STAINLESS STEEL 444 TANK MATERIAL-secondary tank L BARE STEEL (Check one item only) 0 2. STAINLESS STEEL 5. CONCRETE 95. UNKNOWN o 8. FRP COMPTIBLE W/IOO% METHANOL 0 99. OTHER o 10. COATED STEEL 445 TANK INTERIOR LINING I. RUBBER LINED o 5. GLASS LINING 95. UNKNOWN 446 DATE INSTALLED 447 OR COATING (Check one item only) o 2 ALKYD LINING o 4 PHENOLIC LINING ~ 6 UNLINED o 99 OTHER (Forlocal use only) OTHER CORROSION 0 I MANUFACTURED CATHODIC PROTECTION IF APPLICABLE PROTECTION (Check 0"" item only) 0 2 SACRIFICIAL ANODE SPILL AND OVERFILL YEARINSTALLED1ß I 450 (Check all that apply) 0 I SPILL CONTAINMENT ~2DROPTUBE 3 STRIKER PLATE IV. TANK LEAK DETECTION (A description ofth. monitorlng program shall be submitted to the local agency.) IF SINGLE W ALL TANK (Check all that apply) 453 IF DOUBLE WALL TANK OR TANK WITH BLADDER 454 (Check one item only) o I VISUAL (EXPOSED PORTION ONLY) 0 5 MANUAL TANK GAUGING (MTG) 0 I VISUAL (SINGLE WALL IN VAULT ONLY) o 2 AUTOMATIC TANK GAUGING (ATG) 0 6 VADOSE ZONE j8( 2 CONTINUOUS INTERSTITIAL MONITORING o 3 CONTINUOUS ATG 0 7 GROUNDWATER 0 3 MANUAL MONITORING 04 STATISTICAL INVENTORY RECONCILIATION 08 TANK TESTING (SIR) BIENNIAL TANK TESTING D 99 OTHER IV. TANK CLOSURE INFORMATION / PERMANENT CLOSURE IN PLACE o 3 FillERGLASS REINFORCED PLASTIC o 4 IMPRESSED CURRENT 095 UNKNOWN o 99 OTHER 448 DATE INSTALLED 449 OVERFILL PROTECTION EQUIPMENT:YEAR INSTALLED (Forlocal use only) 452 TYPE (local us. only) 451 TßI ø I ALARM ~2 BALL FLOAT 03 FILL TUBE SHUT OFF VALVE o 4 EXEMPT ESTIMATED DATE LAST USED (YR/MOIDAY) 455 ESTIMATED QUANTITY OF SUBSTANCE REMAINING gallons 456 TANK FILLED WITH INERT MATERIAL? DYes D No 457 UPCF (12/99 revised) 10 Fonnerly SWRCB Fonn B ;..,-¡ ., . e e UNIFIED PROGRAM CONSOLIDATED FORM TANKS UNDERGROUND STORAGE TANKS-TANK PAGE 2 VI. PIPING CONSTRUCTION (Check all that aDDlv) Page _ of _ UNDERGROUND PIPING ABOVEGROUND PIPING SYSTEM TYPE tIiC I. PRESSURE o 2. SUCTION o 3. GRAVITY 458 o 1. PRESSURE o 2. SUCTION o 3. GRAVITY 459 CONSTRUCTION 0 1. SINGLE WALL o 3. LINED TRENCH o 99. OTHER 460 o 1. SINGLE WALL 095. UNKNOWN 462 MANUFAcruRER ~ 2. DOUBLE WALL o 95. UNKNOWN 02. DOUBLE WALL o 99. OTHER MANUFACTURER €n 1/1'___ 461 MANUFACTURER 463 o 1. BARE STEEL 06. FRP COMPATffiLE w/lOO% METHANOL o 1. BARE STEEL o 6. FRP COMPATIBLE W/IOO% METHANOL 02. STAINLESS STEEL o 7. GALVANIZED STEEL o Unknown 02. STAINLESS STEEL 07. GALVANIZED STEEL 03. PLASTIC COMPATIBLE WI CONTENTS þ{99. Other 03. PLASTICCOMPATffiLE WI CONTENTS o 8. FLEXIBLE (HOPE) 099. OTHER 04. FIBERGLASS 0 8. FLEXIBLE (HDPE)POV P'/t10re o 4. FffiERGLASS o 9. CATHODIC PROTECTION 05. STEEL W/COATING 09. CATHODIC PROTECTION 464 05. STEEL W/COATING o 95. UNKNOWN 465 VII. PIPING LEAK DETECTION (Check all that apply) (A description of the monitoring Drogram shall be submitted to llielocal aaencv.) * UNDERGROUND PIPING ABOVEGROUND PIPING SINGLE WALL PIPING 466 SINGLE WALL PIPING 467 PRESSURIZED PIPING (Check all that apply): PRESSURIZED PIPING (Check all that apply): o I. ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP SHUT o 1. ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP OFF FOR LEAK, SYSTEM FAILURE, AND SYSTEM DISCONNECTION + SHUT OFF FOR LEAK, SYSTEM FAILURE, AND SYSTEM DISCONNECTION + AUDIBLE AND VISUAL ALARMS. AUDIBLE AND VISUAL ALARMS. o 2. MONTHLY 0.2 GPH TEST o 2. MONTHLY 0.2 GPH TEST o 3. ANNUAL INTEGRITY TEST (O:IGPH) o 3. ANNUAL INTEGRITY TEST (0.1 GPH) o 4. DAILY VISUAL CHECK CONVENTIONAL SUCTION SYSTEMS CONVENTIONAL SUCTION SYSTEMS (Check all that apply) o 5. DAILY VISUAL MONITORING OF PUMPING SYSTEM + TRIENNIAL PIPING o 5. DAlLY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM INTEGRITY TEST (0.1 GPH) SAFE SUCTION SYSTEMS {NO V ALVES IN BELOW GROUNDPIPING): o 6. TRIENNIAL INTEGRITY TEST (0.1 GPH) 07. SELF MONITORING SAFE SUCTION SYSTEMS {NO VALVES IN BELOW GROUND PIPING): GRAVITY FLOW 07. SELF MONITORING o 9. BIENNIAL INTEGRITY TEST (0.1 GPH) 7AßrrY}/sfßT GRAVITY FLOW (Check all that apply): ~ V~~d8r ~ðÞI é-¡t!Clron/~ o 8. DAILY VISUAL MONITORING ::/Þ b4 'b1oo - 001 o 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 AUDffiLE AND VISUAL 10. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL ALARMS AND (Check one) ALARMS AND (Check one) o a. AUTO PUMP SHUT OFF WHEN A LEAK OCCURS o a AUTO PUMP SHUT OFF WHEN A LEAK OCCURS o b. AUTO PUMP SHUT OFF FOR LEAKS, SYSTEM F AlLURE AND SYSTEM Db AUTO PUMP SHUT OFF FOR LEAKS, SYSTEM FAILURE AND SYSTEM DISCONNECTION DISCONNECTION 'Efc. NO AUTO PUMP SHUT OFF DC NO AUTO PUMP SHUT OFF .11. AUTOMATIC LINE LEAK DETECTOR (3.0 GPH TEST) WITH FLOW SHUT 011. AUTOMATIC LEAK DETECTOR OFF OR RESTRICTION 012. ANNUAL INTEGRITY TEST (0.1 GPH) o 12. ANNUAL INTEGRITY TEST (0.1 GPH) SUCTION/GRA VITY SYSTEM SUCTION/GRA VITY SYSTEM o 13. CONTINUOUS SUMP SENSOR + AUDIBLE AND VISUAL ALARMS o 13. CONTINUOUS SUMP SENSOR + AUDIBLE AND VISUAL ALARMS EMERGENCY GENERATORS ONLY (Check all that apply) EMERGENCY GENERATORS ONLY (Check all that apply) o 14. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF· o 14. CONTINUOUS SUMP SENSOR WITHOÚT AUTO PUMP SHUT OFF· AUDIBLE AND VISUAL ALARMS AUDIBLE AND VISUAL ALARMS . o 15. AUTOMATIC LINE LEAK DETECTOR (3.0 GPH TEST) MIHQ!.!I FLOW 015. AUTOMATIC LINE LEAK DETECTOR (3.0 GPH TEST) SHUT OFF OR RESTRICTION o 16. ANNUAL INTEGRITY TEST (0.1 GPH) o 16. ANNUAL INTEGRITY TEST (0.1 GPH) 017. DAILY VISUAL CHECK 017. DAILY VISUAL CHECK VIII, DISPENSER CONTAINMENT , DISPENSER CONTAINMENT o 1. FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE o 4. DAILY VISUAL CHECK DATE INSTALLED 468 ,,g2. CONTINUOUS DISPENSER PAN SENSOR + AUDIBLE AND VISUAL ALARMS o 5. TRENCH LINER I MONITORING o 3. CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR o 6. NONE 469 DISPENSER + AUDIBLE AND VISUAL ALARMS IX. OWNER/OPERATOR SIGNATURE I certify that the infonnation provided flerein is true and accurate to the best of my knowledge. SIGNATURE OF OWNER!' NTÄf DATE ç¡;¿/ kJ';L 470 NAMJc.°~JìX!R!OP:1f~' jFnt) V 471 TITLE OF OWNER/OPERATOR 472 l? S~ / ¡-L L C.F.O. Pennit Nwnber (For local use oftl1 473 Permit Approved (For local use only) 474 Pennit Expiration Date (For local use olÙY) 475 UPCF (12/99 revised) 12 Fonnerly SWRCB Fonn B