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i1NIF3EA PROGRAM CONSOLIDATr,D FORM UNTIE RGROUNDSTORAGEZ`NK MONITORING PLAN (Psg MONITORING , VI�UNDI)ISPFNSE ANT(UOL� — 49D-16 1. OAC MONITORING IS PERFORMED USING THE WOWING M'ITHOD ❑ 1.CONTINUOUS ELP„CTRONIC MONITORING 2f2,FLOAT AND CHAIN ASSEMBLY ❑ 3.ELECTRONIC STAND-ALONG --. ? Q ❑4.NO DISPENSERS _d99.OT1 R�S�em—yf;)� y— a4o-ss MODEL N: � G� / PANEi,MAN[1FACTUAE&_ /.3----- .."�'•..g9Ms7” MODEL#(S)t LEAK SENSORMANUFACTIJRER: n90 s9 ❑ a.VPS NO 400. DETECTION OF A LEAK INTO THE UDC'.TR)GGERS AUDIBLE.AND VISUAL ALARMS ❑ a YES @fNO UDC LEAK ALARM TRIGGERS AUTOMATIC PUMP SHUTDOWN ,9051 FAILURE OISCOMNECT10N 01?UDC MONITORING SYS TEM TRIGGERS AUTOMATIC PUMP SHUTDOWN. ❑�$ESS No 4906z UDC MONIT0R1NCr STOPS TH•FLAW OF PRODUCT ATTHE DISPENSER. YYJJ 4mwr 2.UAC CONST6IJCTTON is .SINGLE,.-WALLED [32.DOUBLE-WALLED + �+ IF AOII6LE WALLED: 2 PRESSURE 3.VACUUM 4m44n UDC INTERSTITIAL SPACE IS MONITORED BYJ�L,Lt UDJ [l_,___._,.=C� -•- A L13AK W[THIN"HE SP.0~ONDARY CONT'AINMbTIT OF TF1,t7DC_TRIGGER,,AUDIBLE AND VISUAL AIARMS�Q a.YES J~..NO VII.PERIODIC SYSTEM TESTING sn 4s. 1, t.LD TESTING: T1US FACR.IrY HAS BEFN NOTIFIED AY THE STATE WATER RESOURCES COT1TR01.BOARD THAT C!iJL6SED +90.66 r D (S F MUST-BE PERFORMED.•PER10DiC ELD_JS PERFORMED BVERY 36 MONTHS A3 REQUIRED.(23 CCR 26??•�)__.,, CONDARv CONTARNMENT COM1'ONENT3 ARR TE3rED EVERY 36 MONTRS. _- •---�--.' --nma7 3.SPILL RIJCETsT3 ARE TESTED ANNUALLY. Thcfollnwing monimringhrmmintenariee records aro kept for thio fncility: (�' term lags +9e.ae. ❑Vistrst inspection Roenrds ,9n.69a ❑Tank Integrity testing resalLs,9o.6es ,41IR te,9ting results(and supporting docamentadon rceords) +9o-ss4 ❑ Tank ganging rasults(and supporting documentation records). n9aa& [7J A1'C Teuing results(and supporting documcnlation records).ago-ssv ❑ Co^nsi°n Pr°mction C�day logy a9a-eeR Equipment msittemmee and mlibmtimf records. n9n-can _ TX.'I'RATNING Personnel with UST monitoring rcsponsibilitics are familiar with all of the fol lowing documents relevant m duetr,job duties. ~6 REPNCE DOCUMENTS MAINTAINED AT FACILITY(Chock all that aPPIy) UNDERGROUND STORAGE TANK MONITORING PLAN(11691499-01 OPERATING MANUALS FOA EI,ECTRONiC MONITORMG EQUIPMENT(RoclLmcd)490ax ❑ CALIFORNIA UNDHROROUND STY7RAGR TANK REGULATIONS+9as94 13CALIFORNIA UNDERGROUND STORAGE TANK LAW nW-69e ❑ STATE WATER RESOURCES CUNTROi. BOARD (SWRCB) PUBLICATION: "HANDBOOK FOR TANK OWNERS - MANUAL AN STATISTICAL INVENTORY RECONCILIATION'496fi9F Q SWRCB PUBLICATION:"UNDERSTANDINGAUTOMATIC TANK GAUGING SYSTEMS"a9anan OTHER(Spxify)'Mrmi,M69i ter Exam administered try the intcmational Code Council(ICC). 's ficitiry has a'Txsigneled UST Operator"who has passed the CaTi'foemialnn amt mnimenm4ce of the USY systems anminlly,and within 30 days of hire.This The"Desigruted UST Operntm will train Ihcility empmyces in ehc prop P training will include,but is not Ifmked fi,the following: D Operation of tlIe UST rystams in a manner consistent with the facility's best management Practices Tho facility employee's role with regardmthe manitanng cgaipmcnt ns specified mthis UST Monitoring Plan A The Facitiry employee's role with regard to spills and overfills os specified in the UST Respomc Plan �� n Namca of conma persmt(s)for cmergcrmics and monitoring alnrms.n9n-m I(, COMMENTS/AADTTIONALINBORMATION fred to this plann9n-7f Prow addkionnl commCllts hem or indicant hum•many Pages with ixlditioraJ MPormaton on spcciflc rmmitaing praceduros aro ntNc . e LCA �S r�� Xl.PERSONNEL RESPOND ITCES The UST Owner/01)MIor is responsible for ensuring that:1)the dailyhoutinc UST monkormg activities and mainlonsnuc of UST leak detection equipment coveted by this plan m:curs.2)ell conditions that indicate a possRdc rel Case we iwc dipped,and 3)all monitoring records are mainminod properly. The following Pers (s)arc responsible lbr prcrformml;the mmrimring and equipment maintenenca: • e99.Ti TITI..E S n9n-7s NAME 4W7+ TITLE, N NAMB ort to the owner/o crater,and inform the owncrkrpemtor of any The Designated UPM10'sbnll W Mem a monthly visual inspection of Me facility,pruvide a roP P condition that need follow-uPlow rmti0n,,�� XIL OWNER/OPERATOR SIGNATURE CERTIFICATION:I certif�tNat 0.information provided ItCle n is tore and acanrde to the hest of m knowledge. 490, r +9a7e DATE: APPI.ICANT'SIGNATU. irlr. r q 0 490.79 ,9o-m APPLICANT TITLE: APPLICANT NAMB(Print): e, 1iPCF UST.D(12 M 310. ffp V 1jj - V