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NIFIED PROGRAM CONSOLIDATED FORM UNDERGROUNDSTORAGETANK MONITORING PLAN- Pee 1 of 3 TYPE OF ACTION ❑ I.NEW PLAN 0 2.CHANGE OF INFORMATION 490.1 PLAN TYPE ® I.MONITORING IS IDENTICAL FOR ALL LISTS AT THIS FACILITY. 4911 (Check one item only) ❑ 2.THIS PLAN COVERS ONLY THE FOLLOWING UST SYSTEM(S)* I. FACILITY INFORMATION FACILITY ID 8(Agency Use Only) I I I _ _ 1 BUSINESS NAME(Same as FACILITY NAME) Circle K Store 02701205 3 BUSINESS SITE ADDRESS 16470 Cambridge Street 10 I CITY Lathrop 104' H. EQUIPMENT TESTING AND PREVENTIVE MAINTENANCE Testing,preventive maintenance,and calibration of monitoring equipment(e.g.,sensors,probes,line leak detectors,etc.)must be performed at the frequency specified by the equipment manufacturers instructions,or annually,whichever is mors frequent,and that such work must be performed by qualified personnel. 3 CCR§2632,2634,2638,2641) - __ MONITORING EQUIPMENT IS SERVICED ® I.ANNUALLY El 99.OTHER(Specify): i6' III.MONITORING LOCATIONS ® L NEW SITE PLOT PLAN/MAP SUBMITTED WITH THIS PLAN. ❑2.SITE PLOT PLAN/MAP PREVIOUSLY SUBMITTED. (23 CCR§2632, 3634)4aw IV.TANK MONITORING IS PERFORMED,USING THE FOLLOWING M"HOp(S): 1.CONTINUOUS ELECTRONIC TANK MONITORING OF ANNULAR(INTERSTITIAL)SPACE(S)OR SECONDARY CONTAINMENT 490.5 VAULT(S)WITH AUDIBLE AND VISUAL ALARMS. (23 CCR 12632,2634) SECONDARY CONTAINMENT IS: ❑ a.DRY ® b.LIQUID FILLED ❑ c.PRESSURIZED ❑d.UNDER VACUUM 4961 PANEL MANUFACTURER: Veeder Root 990'7- ODEL Y: TLS-350 4904 LEAK SENSOR MANUFACTURER: Veeder Root 49xM 9' MODEL#(S): 794380-303 490.1° 2.AUTOMATIC TANK GAUGING(ATG)SYSTEM USED TO MONITOR SINGLE WALLTANK(SL(23 CCR§2643) m PANEL MANUFACTURER: 190.1x. MODEL#: 440'11 IN-TANK PROBE MANUFACTURER; 49014. ^MODEL#(S): 49°15 LEAK TEST FREQUENCY: ❑ a CONTINUOUS ❑ b.DAILYMIGHTLY ❑ e.WEEKLY 4WI6 ❑ d.MONTHLY _ ❑ e.OTHER(Specify): 11117 PROGRAMMED TESTS: ❑ a 0.1&PA ❑ 6.03 g.p.h. ❑ c.OTHER(Specify): �iy ❑ 3.MONTHLYSPATISTICAL INVENTORY RECONCILIATION(23 CCR§2646.1): 410.20 ❑ 4.WEEKLY MANUAL TANK GAUGING(MTG)(23 CCR§2645). TESTING PERIOD: ❑ a.36 HOURS ❑ b.60 HOURS 490.x1 4ao.2x 5.TANK INTEGRITY TESTING(23 CCR§2643.1): 41137 TEST FREQUENCY: ❑ a.ANNUALLY ❑ b.BIENNIALLY ❑ c.OTHER(Specify): wo-u ❑99.OTHER (Specify): 49°'x° 4W2r V.PIPE MONITORING IS PERFORMED USING THE FOLLOWING METHOD(S)(Check all that apply) I.CONTINUOUS MowoRING OF PIPE/PIPING SUMP(S)AND OTHER SECONDARY CONTAINMENT WITH AUDIBLE AND 490.28 VISUAL ALARMS. (23CCR§2636) SECONDARY CONTAINMENT IS:Ms.DRY ❑b.LIQUID FILLED []c.PRESSURIZED ❑d.UNDER VACUUM 4WW PANEL MANUFACTURER: Veeder Root 490"70 MODEL#: TLS-350 490.31 LEAK SENSOR MANUFACTURER: Veeder Root 41042 1 MODEL#(S):_7_94380-208 49°12 PIPING LEAK ALARM TRIGGERS AUTOMATIC PUMP(i.e.,TURBINE)SHUTDOWN. ®a YES ❑b.NO 490.14 FAILURE/DISCONNECTION OF THE MONITORING SYSTEM TRIGGERS AUTOMATIC PUMP SHUTDOWN. ®a.YES ❑b.NO 491'35 2.hIECHAMCAL LINE LEAK DETECTOR(MLLD)THAT ROUTINELY PERFORMS 3.0 g.p.h.LEAK TESTS AND RESTRICTS OR SHUTS OFF PRODUCT FLAW WHEN A LEAK IS DETECTED(23 CCR 12636) _ _ 490.36 MLLD MANUFACTURER(S): Red Jacket / FE Petro 490.37 MODEL#(S): FXI V / MLD 491111 ❑ 3.ELECTRONIC LINE LEAK DETECTOR(ELLD)THAT ROUTINELY PERFORMS 3.0 g.p.h.LEAK TESTS (23 CCR§2636) 490.39 ELLDMANUFACTURER(S) 490-40. MODEL#(S): 49041 PROGRAMMED IN LINE LEAK TEST: ❑ 1.MINIMUM MONTHLY 0.2 g.p.h. ❑ 2.MINIMUM ANNUAL 0.1 g.p.h. 490-12 ELLD DETECTION OF A PIPING LEAK TRIGGERS AUTOMATIC PUMP SHUTDOWN. ❑a YES ❑b.NO 4 3 ELLD FAILURE(DISCONNECTION TRIGGERS AUTOMATIC PUMP SHUTDOWN. ❑a YES O b.NO 4904i 4.PIPE INTEGRITY TESTING 49045 TESTFRE ENCY &ANNUALLY b.EVERY3YEARS ❑ c.OTHER S "i 4/14641043 S.VISUAL PIPE MONITORING. 41041 FREQUENCY ❑ a.DAILY ❑ b.WEEKLY ❑C.MIN.MONTHLY&EACH TIME SYSTEM OPERATED- 49049 •Aalwed W ar, ed m a,H pigicts orly wHSC jZ538Isnort) ❑ 6.SUCTION PIPING MEETS EXEMPTION CRITERIA 123 CCR§2636(1)(3)). 416.50 10 7.NO REGULATED PIPING PER HEALTH AND SAFETY CODE,DIVISION 20,CHAPTER 6.7 IS CONNECTED TO THE TANK SYSTEM 4ao-s1 ❑ 99.OTHER(Specify) 410-sx 410.53 L'PCF UST-D(122007)