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UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK MONITORING PLAN- Page 1 of 21 TYPE OF ACTION [j L NEW PLAN 2.CHANGE OF INFORMATION PLAN TYPE L MONITORING IS IDENTICAL FOR ALL USTs AT THIS FACILITY. (Check one item only) 2.THIS PLAN COVERS ONLY THE FOLLOWING UST SYSTEM(S) I. FACILITY INFORMATION FACILITY ID#(Agency Use Only) BUSINESS NAME(Same as FACILITY NAME) Va BUSINESS SITE ADDRESS1116 � CITY M 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 more frequent,and that such work must be perfortned by qualified personnel. 23 CCR '2632,2634,2638,26411 MONITORING EQUIPMENT IS SERVICED I.ANNUALLY ❑ 99.OTHER(Specify): III.MONITORING LOCATIONS ❑1.NEW SITE PLOT PLAN/MAP SUBMITTED WITH THIS PLAN. 2.SITE PLOT PLAN/MAP PREVIOUSLY SUBMITTED. (23 CCR§2632, 2634 IV.TANK MONITORING IS PERFORMED USING THE FOLLOWING METHOD(S): 1.CONTINUOUS ELECTRONIC TANK MONITORING OF ANNULAR(INTERSTITIAL)SPACE(S)OR SECONDARY CONTAINMENT VAULT(S)WITH AUDIBLE AND VISUAL ALARMS. (23 CCR§2632,2634) SECONDARY CONTAINMENT IS: ❑ ae.�DR�Y��❑ b.LIQUID FILLED c.PRESSURIZED ❑d.UNDER VACUUM PANEL MANUFACTURER, 4+BO.L-__-_-_..-----..---,____MODEL#_� - _____- LEAK SENSOR MANUFACTURER: MODEL#(S): -3JO ❑ 2.AUTOMATIC TANK GAUGING(ATG)SYSTEM USED TO MONITOR SINGLE WALL TANKfSI.(23 CCR§2643) PANEL MANUFACTURER: MODEL-N:-------- IN-TANK ODEL#: ___IN-TANK PROBE MANUFACTURER: _ MODEL#(S): _ LEAK TEST FREQUENCY: ❑ a.CONTINUOUS ❑ b.DAILYINIGHTLY ❑ c.WEEKLY d:MONTHLY _.._____.____-___-0 e.OTHER(Specify) PROGRAMMED TESTS: ❑ a.0.1 g.p.h. ❑ b.0.2 g.p.h. ❑ c.OTHER(Specify): ❑ 3.MONTHLY STATISTICAL INVENTORY RECONCILIATION(23 CCR§2646.1): ❑ 4.WEEKLY MANUAL TANK GAUGING(MTG)(23 CCR§2645). TESTING PERIOD: ❑ a.36 HOURS ❑ b.60 HOURS ❑ 5.TANK INTEGRITY TESTING(23 CCR§2643.1): TEST FREQUENCY: ❑ a.ANNUALLY ❑ b.BIENNIALLY ❑ c.OTHER(Specify): ❑99.OTHER (Specify): V.PIPE MONITORING IS PERFORMED USING THE FOLLOWING METHOD(S)(Check aR that apply) ❑1.CONTINUOUS MONITORING OF PIPE/PIPING SUMP(S)AND OTHER SECONDARY CONTAINMENT WITH AUDIBLE AND VISUAL ALARMS. (23 CCR§2636) SECONDARY CONTAINMENT IS:❑a.DRY ❑b.LIQUID FILLED ❑c.PRESSURIZED []d.UNDER VACUUM _ ._ _.. _ PANEL MANUFACTURER: MODEL#: -___-LEAK SENSOR SENSOR MANUFACTURER: MODEL#(S): PIPING LEAK ALARM TRIGGERS AUTOMATIC PUMP(i.e.,TURBINE)SHUTDOWN. ❑a.YES ❑b.NO FAILURE/DISCONNECTION OF THE MONITORING SYSTEM TRIGGERS AUTOMATIC PUMP SHUTDOWN. ❑a.YES ❑b.NO 2.MECHANICAL LINE LEAK DETECTOR(MLLD)THAT ROUTINELY PERFORMS 3.0 g.p.h.LEAK TESTS AND RESTRICTS OR SHUTS OFF PRODUCT FLOW WHEN A LEAK IS DETECTED(23 CCR_§26361 MLLD MANUFACTURER(S): MODEL#(S): L -Z�O17 ❑ 3.ELECTRONIC LINE LEAK DETECTOR(ELLD)THAT ROUTINELY PERFORMS 3.0 g.p.h.LEAK TESTS (23 CCR§2636) ELLD MANUFACTURER(S) MODEL#(S)..__._.___..____._.-__ PROGRAMMED IN LINE LEAK TEST: ❑ 1.MINIMUM MONTHLY 0.2 g.p.h. ❑ 2.MINIMUM ANNUAL 0.1 g.p.h. ELLD DETECTION OF A PIPING LEAK TRIGGERS AUTOMATIC PUMP SHUTDOWN. ❑a.YES ❑b.NO ELLD FAILURE/DISCONNECTION TRIGGERS AUTOMATIC PUMP SHUTDOWN. ❑a.YES ❑b.NO ❑ 4.PIPE INTEGRITY TESTING TEST FREQUENCY ❑ a.ANNUALLY ❑ b.EVERY 3 YEARS ❑ c.OTHER Specify) ❑ 5.VISUAL PIPE MONITORING. FREQUENCY ❑ a.DAILY ❑ b.WEEKLY ❑c.MIN.MONTHLY&EACH TIME SYSTEM OPERATED' ❑ 6.SUCTION PIPING MEETS EXEMPTION CRITERIA 123 CCR§2636(a)(3)1. ❑ 7.NO REGULATED PIPING PER HEALTH AND SAFETY CODE,DIVISION 20,CHAPTER 6.7 IS CONNECTED TO THE TANK SYSTEM ❑ 99.OTHER(Specify) UpCF UST-D(12/2007)1/4