HomeMy WebLinkAboutSLOUNIFLOW_FS1 Admin iRC3926i Color_2480_001*lun '!6 05 03:20p B And T Servic€ Station C
A Generai i
8059298948 n)
lvf ONITORTNG S YSlItrM CtrRTIFICATIO]Y
.t,:rhoriry ci;ed: cizapter,, [:;,Y;:f{f}jl;';;i::'ff',f;':}';',8,:::,':,,i.7,i{?;:i*,r"rnia code arRegutaiiodr
'l--his forn rnust bc uscrj to documcnt lcsthg end scrvicing of'rronitoring cqujpmcni. A seoarate c*rti6cation or renort rqust be oreparedfor ea-qbi maniroring svstcrn ccntrol Fancl by thc teclrnician whs pcrforms the wsrk. A -"py "f ti-jr fot- r]lust bc providcd io u]* rr"r.
sys(e$r c.wnedbrrcrator= The ownedopaatoimusl submit a eapy of lhis fomr to the iocal agency regulating UST systcrrLs qiL\in 30
days oi t:st datc.
Faeility i{ame:
n
+Bldg. No.:_
Silc Addess:City:L)zip.
'!f r*.a &ci!g c+are.Lqs fircrc t:ny-.s .sr Cispcnrcls, capy thj:form. lnc'ludc idormati*r for ctcy larh *nd dispcnser at tficfacility.
C. Cer"tir'icaticn - { ttrti{y thet ttrr EgtriFmcnt identifird in thic documear rsas i nspeclcdJseniccd in scco rds.nce \rjth llte matrufactl rcn'guideturs. Atlache{i to iftls etriifiuiion js inrt.:-s::ics ic-g. rErrt{rtar$rr{rf ' rhecklirts}acc.33a.ry tc vtrify lhat thir ia{sntration iscorrrcl aad a Plot PIen s!'.ew!ng the layouc of noaircring equiprnent-For rc-v tqriBmcni eapablc cfgcnerating surh refotis. ! have alsortiich.d a e{Ey of thc repo*; (eieecrt aff that aca[*]:Q System set-uF Q Alarm iristery repcrtf-.L ::I CtlultLrdn lYarc
eqttfimu-oq No-:
S=igrufr-rc
I;.-.- \r^ .
n
Teslirgeornpany Name:
-sik AddrBss:
J DNNLJ:
Phone No ,f i
E in-Ta,nk Gaugu:g Probe. trrtodcl:
E ArnujarSpacc or yault Scflsor. Modcl:
0 PipingSurop/ Trcnch Scnsorfs). Modcl;
O Fill Su':rp Scnsor(s), Modcl:
LJ ariccla.'rlcai Linc Lczi( Ortccior. Mocici:{] El:e'.renic Line LeaL DciectQr. !.4odci:
E Tanl Ovcnlll / I{Jgh-Lcvci Senser. Modcl:
Tank iS:
G Clhcr and model in Scc{io:, E on
D A-lnular Spaec .:r Varrh Se nsrt. M+d+!:0 Piping Sump 1?reni.r Sensor{s). Modcl:
O Fill Surp Scnsor(s) Modcl:
G ii,iairmialLlle/LcakDctccto.. Modcl:E Elcctroric Line Leik Dc:cctor. ldodei:B Taol Ouqtf:!l/ High-i-cve! -eccso:, Mcdr!:
ion E on
aakGaugir.g Prorc.Mqdci:
and modal inI] Othcr
E ln-Tarrk Gauging Probc.
O Arrnular Space or Viuir SEnsor"
fi Piping Sun:p I Tnnd. Scnssris).
D Fill Srusp Scn:ori.s).
C h{eelranieal Line Lcak Dciector-
E [lccuuic Lirlc i-.tk Dcrccior-
Il Tank Overfilt / l:igh-lEv-l Scnsar-
lliodcl:
ir{odel:
t la'l - 1.
I\{cdel:
ll{odc[:
$lodcl:
Model:
lypc and wadaZ !n Sactior E sn par!+ 21"E C:tft cr {sp,:eift &*uip mrr i
?ank ID:
Modcl:
Model:
InQqgl:
Mode !:
Model:
Model:
Modcl:
O Ln-Tarrk Garging probc.
G rtn-:lar Spaec or.lfault Sensor.
G PipugSump ttTJench Scnsor{s).
O Fill Surcp Scnsrir{s). /
O Mcchanical tinc Lcak D:leclor.E Elcctronic Lirc Lcak Detcctor.
G Tank Ovcriill / High-Lcvel scnsor.
Eonsrd rdoCe!
Truk ID:
G
B DftacrscrConhinrocnt Sc;rsor{.s} - Model:
tr ShrrrValve(s). '
Dispeaser ID:
fl C6rdainrrcnr rnd
E! Dispcrse.r C+ataiffRnt S€ffods). H.odei:
O Shcar Valvc{s}.
and
Dispcnscr ID:
D
O Dispcn*tCoatainrnca{ Scnsor{s}. Modc!:
n eL--- lf-t-.-t-\! .r! rtr r.
and
Dirpcnscr lD:
l-t
Cl Dispcnstr Cor.iaif, roent Scnso:(s),
D Sircar Vah,e{:1.
Modci:
D
Dispcnser l[;
Con:air.rnei,t
D Dispur:erConlaiffintscnscr(s)_ Modcl
G Shear Yrtvc{:}.
Dispcnser lD;
tr e+a!ais-nrcRt
O Dispuscr Conlainn*nt Sensods)_ Model:Il Shc.tValve{s}-
.Cl . DkF€ns.r Cor,'iainrpcnr Floai(s) md Chairis).
ni.^----- rnu!iPsfr,_M
Daie of Tesiindsewicing: _/ _f _
Jun 16 05 03:20p B And T Service Station e
i'aqr lrrf-i
i\'lilili to rirrg Sysrenr Ctrtilisir f i u rr
I]- Results of Testing/Servicing
So0.rvgrc Vcrsio+ lnsta licd:
follo
- InScciion Ebelorv, deseribetorv and l.Iren lhcse <leficiencics rvere or w.ill be cor
8059298948 p,3
ir rAll
f n^* g^-aF+
L. LSIAt trrEf rts-
Ef ycs D No"l?Is the audible
ffias [] Noi.Is the visual alarm oferationll?
uf-Ycs E Nor Wcrc all scnsols visually insEtqtcd, functicnally tcsred, and eonfinrrcd operational?
6-t'cs Werc all scRso.s installcd at lolvcst point <rf sccon<lary cootrirrlnfnl add positroned so rhat orh:r cquiprrrcnr r.,iil
not inre r[crc *ith their proper operariou'J
IL' YES IJ NO*
dNii,
if alanns arc relayed lo a rcnrerc nronitoring station. is all cornl:runications equipment fc.:. nrodut|
opcrniiontl'l
fi No+
ET-N/A
prcssrrizcd piping q*tcrn!, <iocs tlrc tuibine autorriaticallyshut down if the piping secondar'r,conritin,ncnl
;j1onilorin:: sysiein delccts a leak, fails lo opcrarc. or is clcctrically disconncc:ed? if yes: which sensors initirrc
;r+siti..c strut-do*zr? {Chexl;all tlror upvlfl C S-.;rp/Trnch Sensors-. fl DisperrserConlainrncRr Sensors.
i'or
lJtd ccrr.lfjll {-d$rrq1 due ls t+.r}is scnssr l-?ii{ire/di Ecs.rncclion? E
For t:nk sysiciils that utilize thc r:roriiroring sysleJrr as r]ic priruary u*i nvcrfil] waming davrcc {r.r. no
l.tteellanic:!! o',erfill pfevefltion vnIvc is ins{iillcdi" is ihe ovcrfill 11,.1nling aia.:li visibiE antj a.,ldibir;r-r rhc rank
fillpoinr(s) and operating properly'l ![ so. lr *4r1t pe:een! of trnk cat>aciry dc,es rhe alanrr tritscr? ?2 oA
D Ycs+ffNo
"\'asanvrnoiriroringequiprrrenrrr-placcdl
ll-;.cs,identifyspecifilscftsors.probes.orother
ane{ rnodcl fcr all rcnlacenrcnt rrarrs in Section E. trelou.and list thc ruanufacturgr narue
rr "i^,"^-r ..'^1^-,.,fv\'ul}'llllill ll'|' lduvU
L.J Y C-S-E4o lI as liquid found inside any secocdary containtrenr systcnlr desi.rned as dry sl,stenrs? {Check ali ther <:p1tlt') E
f roducl: fi Waler. If ycs, cjescriirc catrscs in Scetion I:, belox,,
E}-Ycs u t\(t -
'YA5 tll()tlrtcFt rcr.ir:rtcd tc crtsure si 4ttach il ticahlcsclsett
G Ns+$f?es _b 311 f io-r;liirin.q eqliplrsn'L opelariorral pcr ll.lanulacturgt s
')
SAN LUIS OBISPO CITY
Application for Authorization to test an
Underground Storage Tank System
Authority: California Health and Safety Code
Cbapter 6,7 Soction 25289
cld Pennit#
FacilityName: P G & E.
FacilityAdd.tt.' 4325 S. l{ig ttt S* hi
Owner/Operalor:PG&E Mike Newsome
Address: 4325 S. Higuera San Luis Obispo, CA 93401
CONTRACTOR:Na6e: B & T Contractors Contacf Dennis Davenport
666r..r. P O Box 220 Arroyo Grande, C,A. 93421
48L-2552
License: Class: A,B,C6L,D40 TIAZ 623923
TYPEOFTESTING:Leak Monitoring System Certification
Secondary Containment
A. Complete and submit the following for secondary containment testing
_ l. Testing work plan. This plan must include testing method, testing
equipment with manufactures maintenance schedule, calibration
procedure and calibration dates.
_ 2. Component manufactures test requirements
_ 3. Contracton License orTesters Certification
_ 4. Site Health and Safcty Plan
_ 5. Site workers baining certificates
_ 6. lnsurance Certificate
_ 7. Hazardous Waste Handling and Disposal Plan
Date and time of requested 6sq Novenrber L, 2002
B. Complete the following forAnnual Leak Monitoring System Certification
_ l. Contractors License or Testers Certification
2. Testers taining certifications
_ S,Testing equipment calibration procedure and testing date
Date ald time of requested
Applicant (print name ) Dennis
pat", October 31, 2002
Application is: Approved
Conditions:
Denied
RE.H.S.
B & T Service Station Contractors
Test Procedure Information Sheet
PG&E
4325 S. Higuera
San Luis Obispo, CA 93401
I November,20}2I. BUSINESS LICENSE
Attached
2. WORKERS COMP CERTFICATE
Attached
3. PROOF OF LICENSE
Contractor's license attached
4. MANUFACTURER'S 2NDARY CONTAINMENT TESTING PROTOCOLS
5. TESTING EQUIPMENT INFORMATION
Dispenser pans
Turbine sumps
Fill sumps
Tank annulars
Piping annulars
Dispenser pans
Turbine sumps
Fill sumps
Tank annulars
Piping annulars
Dispenser pans
Turbine sumps
Fill sumps
Tank annulars
Piping annulars
None
Waste Oil Tank
Waste Oil Tank
fiberglass
fiberglass
Incon TS-STS Sump Test System
Incon TS-STS Sump Test System
Incon TS-STS Sump Test System
Vacuum gauge
Pressure gauge
Fiberglass cloth, resin and hardener as needed
Fiberglass cloth, resin and hardener as needed
Fiberglass cloth, resin and hardener as needed
Fiberglass cloth, resin and hardener as needed
Glue kits as needed
6. METHOD OF DISPOSAL FOR ALL CLEANING, RINSE & TEST WATER
Each sump and dispenser pan will be inspected for fuel residue. All fuel residue will be
removed using "simple Gr@n" solution and water. The resulting fuel-contaminated
water will be removed using a "thief'vacuum pump and placed in a 55-gallon drum. It
will be manifested transported and disposed of as non-RCRA hazardous waste.
Test water will be teated as indushial wastewater, not non-RCRA hazardous wastewater. It
will be rernoved with a "thief'vacuum pump.
7. REPAIR MATERIAL
, BUSINESS TAX CERTIFICATE PLE4S,q P_9P]]I'A
RECEIPT FOR BUSINESS TAX PAID CONSPICUOUS PLACE
compliance with other ciry regulations, including but not limited to zoning, building code or
other land use regulations (SLOMC 3.01 .102).
possessionof thisbusinesstaxcertificatedoesnotauhorize,permitorallowthebearertodoanyactyrhichbearerwouldnototherwisebelawfullyentitledtodo'
This
;,fi.;;; il;d "trhutt Siury0'SZ*.iness a suoie6 g/gfZU'S0 y*,.::r#,.":fr"lf,n"o,n'".0 s B z 5'"tbt:" 1141 DEL cAMrNo REAL
ARROYO GRANDE CA 93420
CONTRACTOR
ryPE OF BUSINESSB & T SERVICE STATION CONTRS
THOMAS TU],LEDGE
P. O. BOy' 220
ARROYO GRANDE 9342]-
''*u
ot,,w,Hi:P'P"
TAX CERTIFICATE ONLY This certilicate does not constitute proot of
l(1 r a
PaciJic Gas and Electric, Site Safely Plan
SITE SAFETY PLAN
For soil excavation at the
PG&E, San Luis Obispo Service Center
Prepared by
Mike Newsom
Environmental Field Specialist
Environmental Affairs
March 18,2003
,-)
PoctJic Gss and Electric, Site Safety Plan
1.0 BACKGROUND
1.1 Purpose
The purpose of this Site Safety Plan is to assign responsibilities and to establish personal
protection standards, safety procedures, and monitoring requirements that may be
implemented during subsurface activities at former underground hoist sites.
The provisions of this plan are mandatory for all workers during excavation work. It is
the responsibility of all workers involved in the project to contact their supervisor and
request clarification of any questions regarding the Site Safety Plan before beginning any
work on the project.
This Site Safety Plan is designed to provide ample protection to excavation workers and
other employees working in the immediate area.
1.2 Site History
The site has been in operation as a PG&E Service Center since the 1960s. When the
garuge was constructed, a small, underground tank was installed for the waste motor oil.
This tank is gravity fed from the garage and the recyclable motor oil is pumped out
several times ayear by a qualified oil recycling company. A decision was made in2002
to remove this underground storage tank and replace it with one, above ground storage
tank. No prior history of leakage is known.
1.3 Project Description
Date Prepared:
Site Name/Location:
Proposed Dates of Work:
Objective of Work:
March 18,2003
PG&E, San Luis Obispo Service Center
First and second quarter of2003
Install a new, 280 gatlon above ground tank for the garage
waste motor oil. Then, remove the existing underground
storage tank.
t
PactJic Gas and Electric, Site safety PIan
Anticipated or Possible Contaminants :
Land Use of Area Surrounding the Site:
Anticipated Waste Types
Primary Emergency Contacts:
Ambulance:
Fire Department:
Poison Control:
Police:
Industrial
Commercial
Residential
X
Solid
Liquid
911 or 543-2626
91 1 or (805) 781-7380
911 or (800) 662-9886
91 I or (805) 781-7317
PNAs
PCBs
VOCs
TPH
Lift oil
Unknown
X
X
Name, address, phone number, and iJirections to nearest hospital.
French Hospital
1911 Johnson Ave.
San Luis Obispo, CA 93401
(80s) s43-s3s3
Directions from the Site to the Hospital: See Attached Map
3 ,..)
PactJic Gas and Electric, Site Safe$ PIan
Project Contacts:
(Complete to the extent known)
Title Contact Name Telephone Companv
Site Safety Officer (PG&E)
Soil Sampling
Construction Manager Steve Carroll 804-441-3753 C
Project Manager R Harris 80s-s9s-6393
Environmental Coordinator Mike Newsom 805-339-5290 Pgr (PG&E)
Other Contacts (if necessary)
Employees and Contractors acknowledgement of Site Safety Plan briefing.
(To be completed immediately prior to starting of work.)
Print name Employee/Contractor Sisnature
anoll Building)
G&E)
Date
Pacific Gas and Eleclric, Site Safety Plan
2.L Potential Hazards
Substance
2.0 PROJECT H.AZARD EVALUATION
Range of Concentration in Soil
Measured or Expected
Potential
Routes of Entry
Total Petroleum Hazard (TPH) < 1000ppm Ingestion/Absorption
The following additional hazards are anticipated on site: equipment operation, trenching, slip, trips, falls,
heat stress, noise, and possible confined spaces.
2.2 CHENIICAL HAZARDS
Possible hazards result from potential contact with TPH. These chemical compounds may
be present in soils in the form of solids.
2.2.L Metals
Accidental ingestion of metals may occur through inadequate decontamination
procedures or poor personal hygiene practices. Inhalation of metals can occur if
contaminated dust becomes airborne during subsurface exploration. Dermal contact,
particularly to the eyes, is also a concern because ofpossible irritation reactions.
2.3 PHYSICAL HAZARDS
2.3.1 While Drilling and Excavating
Make sure the site is clear of obstructions, debris, etc. prior to beginning the excavation
Work. Potential physical hazards associated with this work include eye and skin contact
hazards, tripping, falling, or slipping during project work, and noise.
In general, soil sampling personnel do not enter excavations because of the hazards of
cave-on, concentration of toxic vapors, and oxygen deficiency. Employees required to
enter an excavation must strictly follow the safe practices described below and all other
applicable safety rules and codes ofsafe practices:
Do not enter an excavation over 4 feet deep unless it is shored or shielded.
It can cave in on you.
Do not enter an excavation whose sides are undermined. It can cave in and
bury you.
a
a
,.l ,-)
Paciftc Gn and Electric, Site Safety Plan
There must be a ladder or other means of entry and exit which extends the
full depth of the excavation within 25 feet of your location within the
excavation
o Do not walk under backhoes, shovels, or other heavy equipment that may
fall or descend on you.
Excavation equipment hazards:
o Most commonly, power excavation equipment such as a backhoe is used
in excavating UST sites, removing USTs, and collecting samples. Safe
work practices include:
Have an assistant guide the driver when in close proximity to hazards or if
clearance is at a minimum.
Be certain of the status of utilities (energized, charged, etc.) in the area of
the backhoe. Call Underground Service Alert (800-642-2444) for
assistance in locating utilities.
Consider overhead lines to be energized. Ensure adequate clearance
when entering a site and loading soil into dump truck or roll-off bin.
Make sure the site is clear of obstructions, debris, etc. prior to beginning
the excavation work.
Maintain proper housekeeping around and on the backhoe at all times.
Store Gasoline only in approved flammable storage containers with spark
arresters.
Check excavating equipment prior to starting work; repair or replace
faulty items.
Watch for slippery ground and backhoe surfaces when mounting or
dismounting the platform.
Unattended excavations must be adequately barricaded or otherwise
protected.
Avoid operating equipment during electrical storms.
a
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04/ 12/01 TIIU 09: 32 FAX
flpr OS Ol O4:?Sp
NORTII POLB , wlo.o?
P.2SanLuis0bispo Citg Fire
)
{8F -r 5.?3-gOl9
I
UNDERGROUND STORAGE TANKS . FACILITV
(ooe Pagc Per sitc)
TANKS
ofPage
I INIFIEI} PRO(IR AM CON.COT .TDATRTI F'ORM
qrccify changc local uc oily D 8' TANK RnMovED(Chcck onc itcrlt ooly)
1l.
400
CI-OSED
4. AM€NDgD PERMIT
FERMIT
O 6.TEM?oRARy slrE cl.osuRE
r. FACTLITY / SITE INFORMA'TION
o7oOoI
Ac(Ll1'Y
I,L
Uil^Doitr8
NEAIIEST CROSS S'fREET 40r
E 5. COUNTY A€ENCYT
D 6. SI.ATDAGENCY.
! 7, FEDERAL AGENCY'
p t.conron*rtoN
E z. tnptvtount-
E ]. PARTN!:RSHIP 40aTYPE [] z. utst'ntnutoR E 4.
l.6As
OTHER .01
ARM
E Ye" EJ tl".OJ
arusrJands?
on Indian Resewation orT
{04
REMAINING A-T SIT.E
,
or offrcccgcrcJr (4lre
u.l records.)opcrales rhc UST (This is lltc conEct pcrron
II. PROPERTY OWNER INFORMATION
.{06
408
.J-
OIT STRb--ET ADDRESS
4W
fre {l?
3,{as'l'
h"Snu Lurrs
4t0
PO
l DISTRICT
4t,
J, COUNTY3.7. FP,DERAL
STATE
ItI. TANK OWNER INFOR]VTATTON
-4qa 6 15
"{- Lttotrut
.11
Ft e-
NER
olt
ztP 419
3 4ot{t6STAn^{ A-r-r r S t si+)1tt
I DISTRICT 420
?, PEDERAL
6. STATE
rv. B0ARD OF EQUALTZATICTN UST STORAGE FEE ACCO(NT NUMBER
,(:lI3TY
V. PETROLEUM UST FINANCIAL RESPONSIBILITY
INDTCATE METIJoDG) D t. spt-p-nrsunr.n
D 2. OUA8ANTEE
D:. tNsur.eNsr
tl r. suRrrv soHo E ?. srAre FUND
E 5, LDTTER OF CREDIT ff 8. STATE FUND & CFO LETTER
O lo- LocAL Govr MECIIANISM
D 99-orttEn,
422E o. gxeupnoN n 9. srATE FtrND & cD
VI. LEGAL NOTTFICATION AND MAILING ADDITESS
D r.rAcrllrY {:. lnrr.ontrotu*ro D t.TANKoWNER 421bcloruscdlcgali !dicartboxQlic
boiunlcss or chccl(cd.will scDlbc rhrlo omcrl!nhoudmtilin8snotilicationsLcgrl
VII. A}PLTCANT SICNATURI]
ftcrcio is tryc rnd G@rc to lhc bcsl of nly knowlcdgc,t--c(ilicnrion - I ctd:ty rhrt lhc
4{04-o t ,/t*E
./
(Fqr locll @ arlYlCERNUMBER (ru kl E only)US'I F
UPCF (l/99 revised)FormerlY SWRCB Fonrr A
T,INIFIED PROGRAM CONSOLIDATED FORM
UNDERGROUND STORAGE TANKS - TANK PAGE 2
lANKS
Vl- PIPING CONSTRUCTION fc),cckdtthrDty)P.gs _ ol
-UNDERGROUND PIPINC ABOVECROUND PIPING
sYsrEM rYPE D t. PR.ESSURT D 2. SUCTION f,:. cn tvrv 458 I r,PREssuR€ 82. sucfloN [[r. cnrrurv {J9
coNsrRucrroN O t. slNcuervlLt-
MANUFAc.uRul{ {r. uot,ott wntl
MANUFACTUPJR
E r. lrt'teo rnrNcH E ee. ornEt{
D ss. uNKNowN
460
a6l
i62
r0l
oil I. SINGLE WALL
2, DOUBLE WALL
MANUFACI'URER
895-vNKNowN
E 99. orHER
E t. BARE S1'EEL B 6. FRp coMpATIBLE ilr00.4 MErlhNoL
E 2. STAINLESSS1'ESL E 7. CALVANIZEI).STEeL E Unkno.*
D l. pr.Asrtc coMpATTBLD wi coN'l'ENTs E 99. orhs
D 4. FIBERGLASS O 8, FLEXBL€ {HDPE)
EI 5. slEEL wc'oATlN(; B 9. cATHoDIc pRorF-cTtoN 464
S r. olReslrer
D l. srAlNLEssSTE€L
D ], PLASTICcoMPATIgLE w/CDNTENTS
fJ 4. fTBERGLASS
D s. sreEu rvrcotrrNo
B 6. FRp CToMPATIBLE wrs% MnruANoL
E 7. cALvANtzED srEEl.
ES.FLE)(IBLEIHDPE) n99. orrftik
D 9. CATItoDlc plto'tEcrloN
E9i. uNKNowN 46,
tlrt offr!
STNCLE \,YALL PIPINC 466
PRESSURJZEII PIPINC (or..r olt rhnr rppty):
0 r. ELEcrRoNlc LINE LEAK DEt EcroR 3-0 cpH TEsr wtrH Auro puMp SHUT
OFF FOR LEAK, SYSTCM FAILUITE, AND SYSTEM DISCOI.I'I{ECTION +
AUDIBLE TlND VISUAT ALARMS.
E z. MUNTKLY o.z cPH'rEsr
fJ 3. ANNUAT- rNT[cnlry rEsT (0,lcplt)
CONV€N'I''ONAL SLICTION 5I'SlEMS
D J. DAILY VISUAL MOMTORING OF PUMPINC SYSTEM { TIUENNIAL III'INO
ln''t EGRIT\ T[Sr (0. I CPIO
SATE SUCTION SYSTEMS (NO VALUES IN BELO\\' OROUNDPiPING):
[] ?. SELF MoNtroR-lNc
cP,AvnY FI.OW
E 9 BIENNIAL rNlEGRrryrrisr{o.r cpt{j
SECONDARILY CONTAINEO PIPTNG
PRESSUIUZEI) PIPING tclEct all r\at apllyr:
IO. CONNNUOUS TUREINE SUMP SENSOR WITH AUI'IBLE AND VISUAL
ALARMS AND (Ohech onc)
D r AUTO PUMP SI{UT OFF wtlEN A LEAK OCCURS
B b. Auro t uMp srruT oFF FoR LEAKS, sysrEM FATLURE AND.sysrEM
DISCONNECIION
flc. No AUrO PUMP SHUToFF
E I I. AUToI'IATIC'-INF. LEAK DETECT0R (!.0 cPH TEST) wJI4 FLoW SHUT
OFF CR R.ESIITICTION
B I?. ANNUAL INTECRITY lEsTiO.I GPH)
SUCTIOI.I/OI'A VITY'SYSTEM
E l]. coN-lrNuous suMI'sENsoR + AUDIBLE, AND vlsuAL ALARMS
tMEnCENCY CENERATORS ONLY (check I'l(hat a{'r'ly)
B t4. coNTlNuous sut!.tp sENsoR wlrlrour Auro puMp sHUTorF.
ATJDIBLE AND VISUALALARMS
$ r s. arrroual'rc ,-rNE LEAr( DETEqToR (t.0 opH TEsr) )vrruoul' FLow
SHUT OTF OR RES ruCTION
O ld. ANNUAL rNTEcRll'y TEsr(0.r GpH)
D r 7. LrAlLv \rlst.,At, cHEcK
SINGLf, WALL PItsING 461
PRPSSURIZED PIPINO (Chek rll trr
'oely):0 r. euEctnoNrc LINE LEAK DETEcToR 3.0 GFH'lesr ylrH Auro PUMI
SHUT OFT FOR IXAK. SYSTEM FAILURE, AND SYSTEM DISCONNECTION t
AUDIBLE AND VISUAL ALARIVIS.
D2. MONTHLYO.?GPHTEST
E 3, ANNUAL INTGGRITY TEST (0,
'CPH)D4. DAILYvlsuAl(:HECK
CONVENTIONAL SUC'IION SYSIEMS {clrc} nll rtur q'plv)
D 5. DAILY VISUAL MONITOilNG OF PIIINC AND PUMPINC SYSTEM
O e. rruEtwrnr lNTEcRrry rEsr (0.t cPH)
SAFE SUCTTON SYSTEMS (NO VALVES lN RF.I.OW cROUND PIPING):
D?. SELFMoNT)'oRtNc
GRAVITY L-LOW (chlck lll (hil rpply):
d8. oellv vrsuAt- MoMTonlNc
n 9. BTENNTAL rNrEcRtrY TEsr (0,t ol'H)
SECONDARILY CONTAINED IIIPING
fIIESSURIZED PlllNG (chcck ill thlt opFly):
IO. CONTINUOUS 1URBINE SUMP SENSOR WTTII AUDIBLE AND VISUA!
ALARIIIS AND (chcck !n!)
EI ! AU}O PUMP SHUT OFF wl$'N A LEAK OCCURS
E b AUTo PUt'f sIIUT oFF FoR LEAKS, svsrEM FAILURE AND sYsl'EM
DISCONNECTION
[]c NoAU]0PUMPSilJTOFT
D I L AUT0MATIC LEAK DETECT0R
D 12. ANNUA!lNTgcRlrY TEST(0.I cPH)
SUCTIONiGRAVITY SYSTEM
E r:. conrnruous suMp sENsoR + AUDIBLE AND vlsuAl AtARMs
EMERGENCY GENEIL{TORS ONI,Y ChlgK lII (fi !! 6PPIY}
E 14. coNTtNuous sutrtP $8N8oR MTHour AUTO puMI sl{ur oFF '
AUDIBLE AND VTSUAL ALARMS
D ts. autovnrlc LINE LEAK lJbTEcroR (1.0 oPH TE$T)
E t6. ANNUAL INTEljnJTV TES'I.(0. ] CPH}
0 tt. pltr-v vIsuALcHtrcK
1(,'
VTU. DISFENSER CONTAI
4. DAILY VISUAL CI{ECK
E ,. r*ENcrt ltt'lEl( /MoNlroRlNo
.80. r,roNe
T)ISP€NSGR CON] A INMEN]'
DATEINSTAT-LED 46r
I. FLOAI MECI{ANI$M TIIAI'ST{UTS OfF SI-IEAR VALVB
B 2. CON I'INUOUS DISPENSER PAN SSNSOR + AUDIBLE AND vlSUAt. ALARMS
E 3, coNTlNuous DISPENSER pAN sENsoR wIl'H AUTo sttur oFF FoR
t
IX. OWNER/OPERATOR
: (ddify rhnl p4vidcd h dE bcrl olmy kp\YHgr.
-/-d
412TI1'E OT OWNER,/OPFRATOR{z €tttUrcad)
475ir ETPintim ortc6or lqil w odly)
04/12/Ol THU 0S:33 FAX
flPn 09 01 04:?5p
NORTH POLE
9,qnl-uis0bispo CirU Fire t i) 543-aol9
rg 004
P.4
UPCF (i/99 rsvised)t2 Formerly SWRCB Form B
04/12/07 THU 09:33 FAX
Fpn OS Ol O4:25p
NORTH POLE
uisObispo Cirs Fire tar ' s43-Aol9
@ oor
s anL p.3
UNDERGROUND STORAGE TANKS - TANK PAGE 1
IJNTFIED PROGRAM CONSOLIDATED FORM
TANKS
lank)
D I NEW SITE PERMTT
dr uut*e,- ttn"n
0 6 TEMPoRARY slTEcLosuRr-
E ? FERMANINTLYcLoSEDoN srlE
Pq:o_-of
-
410
fl a AMENDEDPERMIT O 5cl'lANcEorlNFoRMATloN
(sFr(y r.tsotr - aorlNrl u$3 ontvl (spNlry nNon- tor twnl wc oflly)O I TANKn!:MovED
TYPE OT'ACTION
((:hc!t o,r! ils$oillv)
bI@I,l b ()o otoo!
ID:NAMg (s6n'. n' rAclLIR NAMEo. llBA Doirs B{!in.s. Ar)
a{-lc
lTl{lN Sl'l'E (oprionali
alt
Grt(Aft.
ro th! local ageDcy.)
with the locadon.TANK sysicff(A /tI.
lC"Yg". lomFlcb one pagc for rlcb tomPttuc[t
ffiYesEfNo4tlTANK MANUFACTURERTfl
ALr,liD{YDATE
(l:or locrl s.oDly)
WAs-rE- Morar<-Ot t-
ANK CON
allCOMPARTMENTSNUMBE,RTANK
I
418
so
US
E lc,MIDGnADEUNLEADED D4.cAsoHoL
COMMON NAt9lE (trv", Haa,dog MaE i'l' lnltnlory n'sc)
II. TANK CONTENTIi
1'YPE
(fronl l{aanJous MJ.tilts lnYcnlory p'tc )
o l. MoToR vEl{tcLE FUbL
{lt$tlrltglconplcli PclNldd Trtc}
D 2, NON-ruEL PETROLEUM
0 3. CHEMICAL PltoDucr
EF4. HAzARDous wAsrE
(lrEludc5 Usid Oil)
B s:. uNrNowll
/anta
U ra. RF.GULAftUNLEADED Ez. uauco
0 rt. p*gt"ltuvuNlEAllED El. DIESEL
D 5. JE,I.FTIET.
D6. AVIATIONIUEL
E cc. otHun
tc\ccl oNt hurh onty)
f:htcl osc ilenronlv)
wTl{L
g t. fRPCoMPTIBLE w1009'oMErlrnnol E 9e' orllER
Ez. DoUDLE$'A[
O95. UNKNOWN
E 99. oTrGR
EXI.ERIOR MEMBI(ANE LINER
84, SIGNLEWALLIN VAULT
E 2. stAINLES$ srEEL E 4- 51p51916pv/HaERcLAss
REINFORCED PLAsrlc (l'Rr)
U2. STATNLESSSTEDL 94. STEELCLADWFIBERGLASS
REINFORCED PLASTIC (FRP)
Ds. coxcntrr
-- $coMryidk
tctcc\ ons ilcm dillyl
S'TEEL
E E. FFf col"frlglE wnoo% METHANoL O 99. orH-L:R
fI Io.COATEDSTEEL
E2ALKYDLTNINC B4PHENoLICLININc D6lt'lLlNED D 99 OTHER
[For lecsl s€ ollt)
DACLASS3.I. RUBBER
OR COATIN(i
(Chccli 0tr. iNln lnlyl
tfq lsal usr ur\)
{8
D I MANUT]ACTURED CATHODIC CI 3 FIBEXGLASS REINFORCE9 PLASTIC
oTHER COzuTOSION
fl 4 IMpRE$SEDGURRENTTROTECTION IF APPLICAtsLE PRO'I'SCTION
E c seczurlctal eNooniclEc[oR iEnr NIY!
EIss uNxl-lowb'l
D tc otuL-n
E 3 FILTTUBE SHUTOFf VALVI:
D.1 EXEMPT
d' oto*t
Ez seLLrlonr
If I SPILLCONTAINMENT
D : DrroP TUBE
TYPE (ml ueonlv;INSTL
tt:h-ca sil [$l 40lY)
SP'LL
3 STKIKER PLATE
rhall bc subf,rirrod ro thc lq@l.8!n9y.)
{A dcrcriFtiot o[ lftcrV. TANK LEAK
lctreck orr ihm onlY)
ij-i vrsu.rr- tsiuolE wALL tN vAUL I oNLY)
(z coHttnuout lNTERsrlrlAL MoNIroRlNc
E 3 MANUAL MONITORJNC
45{wtTuKORTIFw
n t vlsuAl (exl'osED PoRTloN ONLY)
1:l 2 Au roMA l tc IANK oAUclNC (^Tc)
E 3 coNrlNuous A'l'G
B 4 srA'l]s]lcAl- INvENToRY REcoNclLlATIoN
E 5 MANUAL TANK CAUCINC (h4TC)
E 6 vaDosE zoNF.
O ? cR{luNDwdl[R
B 8'TANK TESTING
E ss o'rtren
iF SINOLE W TANK (ClEtk sllrhrl ipplt)
(s1R)BIENNIAL TANK TESTINO
IV. TANK CLOSUR.E
IAIIIK FILLF.D WITH INERT MA'I'EIiIAI''I
E Yes D t"toE$TIMATED QUANTN'Y OF SUfB$1"TNCE REMATNING
gallons
NSTIMATED DATE LAST USED (YN'/MO/DAY)
LIPCF (l/99 revised)l0 Frrunerly SWRCII Fonn B
)
j
I lf,ltElErr DDnnDAnt ,t lD\ ErrE it
UNDERGROUND STORAGE TANKS - FACILITY
(one page per site)Page _1_ of _1_
TYPE OF ACTION f] 1. NEW SITE PERMIT
(Check one item only) ! 2. INTERIM PERMIT
E 3. RENEWAL PERMIT
E 4. AMENDED PERMIT
D s.CHANGE OF INFORMATIoN
f] o,TEMPOMRY SITE CLOSURE
! T.PERMANENTLY CLOSED SITE
El 8. TANK REMoVED 4oo
I. FACILITY / SITE INFORMATION
BUSINESS NAME lsame as rAclLlTY NAME or DBA)
PG&E - San Luis Obispo Service Center
3 FACILITY ID#F A 0 0 0 5 1 8 3
'l
TYPE ! 2. DTSTRTBUTOR E 4. PROCESSOR E 6. OTHER
403
uera and Los osos Val Road
BUSINESS 1. GAS STATION 3. FARM 5, COMMERCIAL
NEAREST CROSS STREET 401 FACILITY OWNER ryPE
X 1, CORPORATION
! 2. rNDrVrDUAL
E 3. PARTNERSHIP
! +. locRu ncENcy/DrsrRrcr-
[ 5. COUNTYAGENCY-
E 6. STATE AGENCY"
E 7. FEDEML AGENcy.
4o2
404
TOTAL NUMBER OF TANKS
REMAINING AT SITE
4, above ground
ls facility on lndian Reservation or
trustlands?
fl Yes X No 4o5
"lf owner of UST is a public agency: name of supervisor of division, section or
offibe which operates the UST (This is the contact person for the tank records.)
406
II. PROPERTY OWNER INFORMATION
PROPERTY OWNER NAME
PG&E Contact Person: Rusty Harris
407 408PHONE
595-6393
MAILING OR STREET ADDRESS
406 Higuera Street
409
San Luis Obispo
410CITY 411STATE
CA
412ZIP CODE
93401
X 1. CORPOMTION E 2. INDIVIDUAL N 4. LOCAL AGENCY / DISTRICT E 6. STATE AGENCY
f] 3. PARTNERSHIP E s, COUNW AGENCY E Z EOCNRL AGENCY
PROPERTY OWNER TYPE
413
III. TANK OWNER INFORMATION
TANK OWNER NAME
PG&E
4't4 PHONE 415
MAILING OR STREET ADDRESS
406 Higuera Street
416
San Luis Obispo
4',t7CITY 414STATE
CA
419ZIP CODE
93401
X 1. CORPORATION f] 2. INDIVIDUAL f] 4, LOCAL AGENCY / DISTRICT
! 3. PARTNERSHIP E 5. COUNTYAGENCY
TANK OWNER TYPE ! 6, STATE AG ENCY 420
f] 7- FEDERALAGENCY
IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER
TY (TK) HQ 44.0 0 2 8 8 Call (916) 322-9669 if questions arise4 421
V. PETROLEUM UST FINANCIAL RESPONSIBILITY
f] 7. STATE FUND
E 8. STATE FUND & CFO LETTER
E 9. STATE FUND & CD
E 10. LOCAL GOV'T MECHANISM
! 99. OTHER:-
422
xl 1. SELF-TNSURED
E 2. GUARANTEE
E 3. INSURANCE
! 4. SURETY BOND
f] 5. LETTER OF CREDIT
E 6. EXEMPTION
INDICATE
METHODIsl
VI. LEGAL NOTIFICATION AND MAILING ADDRESS
8 2. pRopERw owNER D 3. TANK owNER 423
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 1 or 2 is checked I t. FACILITY
VII. APPLICANT SIGNATURE
Certification - I certify that the information provided herein is true and accurate to the best of my knowledge.-q.q-r--S: lf
SIGNATURE OF APP DArE 3 *18 tri 424 PHONE €9ffi393-425
TITLE OF APPLICANT -F+ojeel{4anager 'Dz*:= S. r?:427
OFFICIAL USE ONLY DATE RECEIVED CUPA PA DISTRICT/INSPECTOR
STATE UST FACILITY NUMBER 428 4291998 UPGRADE CERTIFICATE NUMBER
UP FORM (112000 Version)
SBC UST-A.doc
Formerly SWRCB Form A
uNrF|ED PROGRAM (UP) FORM
UNDERGROUND STORAGE TANKS - TANK PAGE 1
1of2
TYPE OF ACTION tr 1 . NEW SITE PERMIT
(Check one item only) E 2. INTERIM PERMIT
83. RENEWAL PERMIT
N 4, AMENDED PERMIT
E 5.cHANGE oF INFoRMATIoN
E o.TEMPOMRY SITE CLOSURE
! T.PERMANENTLY CLOSED SITE
8 8. TANK REMOVED 430
BUSINESS NAME lsame as FAclLlry NAME or DBA )
PG&E - San Luis Obispo Service Center
FACILITY ID:
F A 0 0 0 5 1 8 3
1
LOCATION WITHIN SITE loptionatl At Southeast side of Garage 431
I. TANK DESCRIPTION
(A scaled plot plan with location(s) of UST system(s) including buildings and landmarks shall be submitted to the CUPA or PA.)
432TANK ID #
UNK
433TANK MANUFACTURER
Modern Weldinq
COMPARTMENTALIZED TANK U YeS X No
lf "Yes", complete one page for each compartment.
434
DATE TNSTALLED (YEARyMO)
87t10
435 436TANK CAPACITY IN GALLONS
520 qallons
NUMBER OF COMPARTMENTS
One
437
ADDITIONAL DESCRIPTION (For local use onty)438
II. TANK CONTENTS
PETROLEUM TYPE
E 1a. REGULAR UNLEADED
E 1b. PREMIUM UNLEADED
! 1c. MIDGMDE UNLEADED
E 2. LEADED
E 3. DIESEL
E] 4. GASOHOL
[ 5. JET FUEL
! 6, AVIATION FUEL
I 99. oTHER: Motor Oit
440TANK USE
! 1, MOTOR VEHICLE FUEL
(lf marked complete Petroleum Type)
X 2. NON-FUEL PETROLEUM
D 3. cHEMICAL PRoDUCT
E 4. HAZARDOUS WASTE (lncludes Used Oil)
E 95. UNKNoWN
439
COMMON NAME
(from Hazardous Materials lnventory page)
Motor Oil, waste
44'l CAS#
(from Hazardous Materials lnventory page)
442
ill TANK GONSTRUCTION
LI 3. SINGLE WALL WITH
EXTERIOR MEMBRANE LINER
E 4- SIGNLE WALL IN VAULT
E 5. SINGLE WALL WITH INTERNAL BLADDER
E 95. UNKNOWN
E 99. OTHER _
TYPE OF TANK
((Check one item only)
El 2. DOUBLEWALL
443
LJ 1. SINGLEWALL
TANK MATERIAL - primary tank E 1. BARE STEEL
((checkoneiremonly) !2. STAINLESSSTEEL
f] 3. FIBERGLASS / PLASTIC
8 4. STEEL CLAD WFIBERGLASS
REINFORCED PLASTTC (FRP)
! 5. CONCRETE E 95. UNKNoWN
! 8. FRP COMPTIBLE W/IOO% METHANoL D 99, oTHER 444
TANK MATERIAL - secondary tank Ll 1. BARE STEEL E 3. FIBERGLASS / PLASTIC E 5. CONCRETE E 95. UNKNOWN
((ChECKONEitEMONIY) !2. STAINLESSSTEEL !4. STEELCLADWFIBERGLASS 88. FRPCOMPTIBLEW/IOO%METHANOLEgg.OTHER 445
REINFORCED PLASTIC (FRP) tr 10. COATED STEEL
! 3. EPOXY LINING
E 4 PHENOLIC LINING
TANK INTERIOR LINING
OR COATING
(Check one item only)
f] 1. RUBBER LINED
N 2ALKYD LINING
! 5. GLASS LINING
D 6 UNLINED
X 95. UNKNOWN
! 99 OTHER 446
447DATE INSTALLED
1987
(For local use only)
f] 95 UNKNOWN
D 99 OTHER
OTHER CORROSION E 1 MANUFACTURED CATHODIC N 3 FIBERGLASS REINFORCED PLASTIC
PROTECTION (IF APPLICABLE) PROTECTION ! 4 IMPRESSED CURRENT
(check one item onry) E 2 SACRIFICIAL ANODE
444
444DATE INSTALLED
(For local use only)
SPILL AND OVERFILL
YEAR INSTALLED 452
1 987
(Check all that apply)
! 1 SPILL CONTAINMENT
X 2 DROPTUBE
X 3 STRIKER PLATE
450YEAR INSTALLED
1 996
ryPE (local use only) 451 OVERFILL PROTEGTION EQU IPMENT
X 1 ALARM
X 2 BALL FLOAT
E 3 FILL TUBE SHUT OFF VALVE ! 4 EXEMPT
D 1 VISUAL (EXPOSED PORTION ONLY)
D 2 AUTOMATIC TANK GAUGING (ATG)
! 3 CONTINUOUS ATG
E 4 STATISTIcAL INVENToRY REcoNcILIATIoN
(SIR) + 61611P141 TANKTESTING
E 5 MANUAL TANK GAUGING (MTG)
E 6 VADOSE ZONE
E 7 GROUNDWATER
! 8 TANK TESTING
E 99 OTHER
of the
454BLADDER
shall be submitted to the local
(Check one item only)
lV. TANK LEAK DETECTION rn
lF SINGLE WALL TANK (check atr that apply)
E 1 VISUAL (SINGLE WALL IN VAULT ONLYJ
EI 2 CONTINUOUS INTERSTITIAL MONITORING
E 3 MANUAL MONITORING
V. TANK CLOSURE INFORMATION / PERMANENT CLOSURE IN PLACE
455ESTTMATED DATE LAST USED (YR/MO/DAY)
Aoril 13. 2003
456ESTIMATED QUANTITY OF SUBSTANCEREMAINING
One Gallon
457TANK FILLED WITH INERT MATERIAL?
DYes I No
OFFICIAL USE ONLY DATE RECEIVED CUPA PA DISTRICT/INSPECTOR
UP FORM (1/2000 Version)
SBC UST-B.doc
Formerly SWRCB Form B
I UNIFIED (uP) FORM
UNDERGROUND STORAGE TANKS _ TANK PAGE 2
Vl. PIPING CONSTRUCTTON (Check ail that a 2of 2
UNDERGROUND PIPING ABOVEGROUND PIPING
SYSTEM TYPE E 1, PRESSURE D 2, SUCTION El3. cRAVtw 458 I3. cRAVrry 459E 1. PRESSURE D 2. sucloN
coNSTRUcTIoN 8 1. SINGLE WALL
MANUFACTURER E 2. DOUBLEWALL
MANUFACTURER
! 3. LINED TRENCH f]99. oTHER
E 95. UNKNOWN
460
461
8 1. SINGLE WALL
E 2. DoUBLE WALL
MANUFACTURER
O 95. UNKNoWN
E 99. OTHER
462
463
HSJt?,tlRX*N tr 2. sTATNLESS srEEL
D 3. PLASTIC CoMPATIBLE W/ CoNTENTS
E 4, FIBERGLASS
D 5. STEEL WCoATING f] 99. oTHER
METHANOL
f] 7. GALVANIZED STEEL
! 8. FLEXTBLE (HDPE)
! 9. cATHoDIc PRoTEcTIoN
6. FRPCOMPATIBLE WlOO%
464
IALS AND 8 ,1. BARE STEELcoRRosroN
82. STAINLESS STEEL
83. PLASTIC coMPATIBLE
W/CONTENTS
E 4. FIBERGLASS
! 5. STEEL W/CoATING
E o. rnp coMpATIBLE wloo% METHANoL
D 7. GALVANIZED STEEL
E 8. FLEXIBLE (HDPE) tr 95, UNKNoWN
E 9. CATHoDIC PRoTEcTIoN
E 99. orHER 465
81. BARE STEEL
LEAK DETECTION all that of the shall be submitted to lhe loml
UNDERGROUND PIPING ABOVEGROUND PIPING
SINGLE WALL PIPING 466
PRESSURIZED PIPING (Check ail tharappty):
! 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
D 3. ANNUAL INTEGRITYTEST (o,1GPH)
CONVENTIONAL SUCTION SYSTEMS (check al thar appty)
D 5, DAILY VISUAL MoNIToRING oF PUMPING SYSTEM + TRIENNIAL PIPING
INTEGRITY TEST (0.1 GPH)
SAFE SUCTION SYSTEMS (NO VALUES IN BELOW GROUNDPIPING):
8 7. SELF MoNIToRING
GRAVIry FLOW
E e. BTENNtAL |NTEGRtry TEST (0.1 cpH)
SECONDARILY CONTAINED PIPING
PRESSURIZED PIPING (Check att that appty):
10, CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL
ALARMS AND (Check one)
E a. AUTO PUMP SHUT OFF WHEN A LEAK OCCURS
D b. AUTO PUMP SHUTOFF FOR LEAKS, SYSTEM FAILUREAND
SYSTEM DISCONNECTION
Dc. NO AUTO PUMP SHUT OFF
E 11. AUToMATIC LEAK DETECToR (3.0 GPH TEST) WITHFLoW SHUT oFF
! 12. ANNUAL tNTEGRtry TEST (0.1 cpH)
SUCTION/GRAVITY SYSTEM
D 13. CONTINUoUS SUMP SENSoR + AUDIBLE AND VISUAL ALARMS
EMERGENCY GENERATORS ONLY (Check ail that appty)
! 14. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF -
AUDIBLE AND VISUAL ALARMS
! 15. AUToMATtc LEAK DETECToR (3.0 cpH) wtrHour FLow SHUT oFF
! 16. ANNUAL INTEGRITYTEST (0.1 GPH) E 17. DAILYVISUAL cHEcK
PRESSURIZED PIPING (check ail rhat appty):
f] 1. ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUIO PUMP
SHUT OFF FOR LEAK, SYSTEM FAILURE, AND SYSTEM
DISCONNECTION + AUDIBLE AND VISUAL ALARMS.
E 2. MoNTHLYO.2 GPH TEST
! 3.ANNUALINTEGRITYTEST(o.1GPH) D4. DAILYVISUALcHEcK
CONVENTIONAL SUCTION SYSTEMS (checi ail rhat appty)
D 5. DAILY VISUAL MoNIToRING oF PIPING AND PUMPING SYSTEM
! 6. TR|ENN|AL tNTEGRtTy rEST (0.1 cpH)
SAFE SUCTION SYSTEMS (NO VALVES IN BELOW GROUND PIPING):
El 7. SELF MoNIToRING
GRAVIry FLOW (Check ail thar appty):
EB. DAtLy vlsuAl MoNtToRtNG De. B|ENNtAL tNTEGRtry TEST (0 1 cpH)
SECONDARILY CONTAINED PIPING
PRESSURIZED PIPING (Check ail that appty):
10. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL
ALARMS AND (Check one)
D a AUTO PUMP SHUT OFF WHEN A LEAK occURS
f] b AUTO PUMP SHUTOFF FOR LEAKS, SYSTEM FAILUREAND SYSTEM
DISCONNECTION
Dc NOAUTOPUMPSHUToFF
E 11. AUToMATIC LEAK DETECToR
D 12. ANNUAL tNTEGRtry TEST (0.1 GpH)
SUCTION/GRAVITY SYSTEM
D 13. CONTINUoUS SUMP sENsoR +AUDIBLE ANDVISUALALARMS
EMERGENCY GENERATORS ONLY (check alt rhat appty)
E 14. coNTINUoUS SUMP sENsoR WITHoUT AUTo PUMP sHUT oFF -
AUDIBLE AND VISUAL ALARMS
! 15. AUToMATtc L|NE LEAK DETECToR (3.0 GpH TEST)
467
! 16. ANNUAL tNTEGRtry rEST (0.1 c PH) E 17. DAILY VISUAL CHECK
SINGLE WALL PIPING
VIII. DISPENSER CONTAINMENT
DISPENSER CONTAINMENT
DATE INSTALLED 468 E 5, TRENCH LINER / MoNIToRING
El 6. NoNE 46e
E 2. CONTINUOUS DISPENSER PAN sENsoR + AUDIBLE AND VISUAL ALARMS
FORCONTINJUUODSEISPnRNSESENSORPANAUTOOFFSHUTWITH
D +D
f] 1. FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE N 4. DAILY VISUAL cHEcK
IX. OWNERYOPERATOR SIGNATURE
I certify that the information provided herein is true and accurate to the best of my knowledge.
470
t
NAME OF OWN
472
OFFICIAL USE ONLY Permit Number 473 Permit Approved 474 Permit Expiration Date 475
UP FORM (1l20OO Version)
SBC UST-B.doc
3 Formerly SWRCB Form B