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UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK MONITORING PLAN-(Page 1 of 2) TYPE OF ACTION ❑JNEW PLAN iff 2.CHANGE OF INFORMATION 4WI PLAN TYPE 1.MONITORING IS IDENTICAL FOR ALL USTs AT THIS FACILITY. 490-2 (Check one item only) ❑ 2.THIS PLAN COVERS ONLY THE FOLLOWING UST SYSTEM(S)- L FACILITY INFORMATION FACILITY ID#(Agency Use Only) BUSINESS NAME(Same as FACILITY NAME) QT120 1 OT 0 A ; BUSINESS SITE ADDRESS S D� �(.-1 r e 103. CITY p 104. H.EQUIPMENT TESTING AND PREVENTIVE MAINTENANCE' Testing,preventive maintenance,and calibration of monitoring equipment(c.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 performed by qualified personnel. 23 CCR 2632,2634,2638,2641 MONITORING EQUIPMENT IS SERVICED 1.ANNUALLY ❑ 99.OTHER(Specify): 490-3b TIL MONITO CAT LOIONS ❑1.NEW SITE PLOT PLAN/MAP SUBMITTED WITH THIS PLAN. .SITE PLOT PLAN/MAP PREVIOUSLY SUBMITTED. (23 CCR§2632, 2634)4904 IV.TANK MONITORING IS PERFORMED:USING THE FOLLOWING.METHOD(S):. . I.CONTINUOUS ELECTRONIC TANK MONITORING OF ANNULAR(INTERSTITIAL)SPACE(S)OR SECONDARY CONTAINMENT 4905 VAULT(S)WITH AUDIBLE AND VISUAL A1,ARMS. (23 CCR§2632,2634) SECONDARY CONTAINMENT IS: VT a.DRY ❑ b.LIQUID FILLED ❑ e.PRESSURIZED ❑d.UNDER VACUUM 49 PANEL MANUFACTURER /' �` CWT-T-MOD LEAK SENSOR MANUFACTURER: I E 090.9' I MODEL#(S): 490-10 2.AUTOMATIC TANK GAUGING(ATG)SYSTEM USED TO MONITOR SINGLE WALL TANK(S).(23 CCR§2643) 490-11 PANEL MANUFACTURER: 49x12. MODEL#: 4W13 IN-TANK PROBE MANUFACTURER: 490-14. MODEL#(S): --___----� 490-15 LEAK TEST FREQUENCY: ❑ a.CONTINUOUS ❑ b.DAILY/NIGHTLY ❑ c.WEEKLY 49046 ❑ d.MONTHLY ❑ OTHER(S ): 4W11 (Spm ...490-18 PROGRAMMED TESTS: ❑ a.0.1 g.p.h. ❑ b.0.2 g.p.h. ❑ c.OTHER(Specify): 490-19 ❑ 3.MONTHLY STATISTICAL INVENTORY RECONCILIATION(23 CCR§2646.1): 490-20 ❑ 4.WEEKLY MANUAL TANK GAUGING(MTC)(23 CCR§2645). TESTING PERIOD: ❑ a.36 HOURS ❑ b.60 HOURS °90-21 490-22 ❑ 5.TANK INTEGRITY TESTING(23 CCR§2643.1): 490-23 TEST FREQUENCY: ❑ a.ANNUALLY ❑ b.BIENNIALLY ❑ c.OTHER(Specify): 49034 Q ( P fY) 490-25 ❑ 99.OTHER (Specify): <�27 V.PIPE MONITORING IS PERFORMED USING THE FOLLOWING METHOD(S)(Check all that apply) 1.CONTINUOUS MONITORING OF PIPE/PIPING SUMP(S)AND OTHER SECONDARY CONTAINMENT WITH AUDIBLE AND 490'28 VISUAL ALARMS. (23CCR§2636) SECONDARY CONTAINMENT IS:Fla.DRY ❑b.LIQUID FILLED ❑c.PRESSURIZED ❑d.UNDER VACUUM 090.39 ------------------ PANEL MANUFACTURER: �el °�'�y MODEL# 490-31 '. LEAK SENSOR MANUFACTURER!, 1 1 - 49632 -MODEL#(S): L S b 490-33 PIPING LEAK ALARM TRIGGERS AUTOMATIC PUMP(i.e.,TURBINE)SHUTDOWN. 1 ❑a.YES [+d NO 490-34 FAILURE/DISCONNECTION OF THE MONITORING SYSTEM TRIGGERS AUTOMATIC PUMP SHUTDOWN. ❑a.YES 91<.NO 490-35 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$2636 49036 MLLD MANUFACTURER(S): 490-37 MODEL#(S): 49x38 ❑ 3.ELECTRONIC LINE LEAK DETECTOR(ELLD)THAT ROUTINELY PERFORMS 3.0 g p.h.LEAK TESTS (23 CCR§2636) 4W39 ELLD MANUFACTURERS °9040 --_--_----__ _-�___.-- PROGRAMMED IN LINE LEAK TEST: ❑ 1.MINIMUM MONTHLY 0.2 g.p.h. ❑ 2.MINIMUM ANNUAL 0.1 g.p.h. 49042 ELLD DETECTION OF A PIPING LEAK TRIGGERS AUTOMATIC PUMP SHUTDOWN. ❑a.YES ❑b.NO 09043 LD FAI.UREIDISCONNECfION TRIGGERS AUTOMATIC PUMP SHUTDOWN. ❑a YES [Ib.NO °90.°6 4.PIPE INTEGRITY TEISTJNG 49045 TEST FRE UENCY [�'a.ANNUALLY D b.EVERY 3 YEARS c.OTHER S mi 4904649047 5.VISUAL PIPE MONITORING. 49048 FREQUENCY ❑ &DAILY ❑ b.WEEKLY ❑C.MIN.MONTHLY&EACH TIME SYSTEM OPERATED' 49049 *Allowedfoamiwfin fmbunN a wr fuel piping only,r H$ 25281 5(b)(3 ❑ 6.SUCTION PIPING MEETS EXEMPTION CRITERIA l23 CCR§2636(a)(3)I• 490-50 ❑ 7.NO REGULATED PIPING PER HEALTH AND SAFETY CODE,DIVISION 20,CHAPTER 6.715 CONNECTED TO THE TANK SYSTEM 490-51 ❑ 99.OTHER(Specify) 490-53 UPCF UST-D(12/2007)1/4