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L AFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK M1IONITORINGPLAN (Page2o(2) VI. UNDER DISPENSER CONTAINMENT (UDC) MONITORING I. UDC MONITORING IS PERFORMED USING THE FOLLOWING METHOD 41)(1-54a 4x) -sob , 1. CONTINUOUS ELECTRONIC MONITORING 1-12. FLOAT AND CHAIN ASSEMBLY ❑ 3. ELECTRONIC STAND-ALONE I ❑ 4. NO DISPENSERS ❑ 99. OTHER (SFec3fv): -- _ --- —--- i ----------------------- ——___—_- ---^ PANEL MANUFACTURER: 491 -ss T MODEL #: 'l'L, zj50 4�a5F. LEAK SENSOR MANUFACTURER: _V� lr a'n sr 1 MODEL #(S): G} �{�� - ?jz.� •+'x1-51 —�— --- - DETECTION OF A LEAK INTO THE UDC TRIGGERS AUDIBLE AND VISUAL ALARMS a. YES ❑ b. NO 1x1 s° UDC LEAK ALARM TRIGGERS AUTOMATIC PUMP SHUTDOWN a. YES ❑ b. NO 490-6G.I FAILURE / DISCONNECTION OF UDC MONITORING SYSTEM TRIGGERS AUTOMATIC PUMP SHUTDOWN. ® a. YES ❑ b. NO JIM -61 UDC MONITORING STOPS THE FLOW OF PRODUCT AT THE DISPENSER a. YES ❑ b. NO 490-62 w 490-63 2. UDC CONSTRUCTION IS XI. SINGLE -WALLED ❑ 2. DOUBLE -WALLED _-- — _ IF DOU BLE %VALLEV, rw r4a UDC_ INTERSTITIAL SPACE IS MONITORED BY: Ell -LIQUID 2. PRESSURE 3. VACUUM A LEAK WITI•TIiV THE SECONDARY CONTAINMENT OF THE UDC TRIGGERS AUDIBLE AND VISUAL ALARMS ❑ a. YES ❑ b. NO 4'liu4n VII. PERIODIC SYSTEM TESTING El 1. ELD TESTING THIS FACILITY HAS BEEN NOTIFIED BY THE STATE WATER RESOURCES CONTROL BOARD THAT ENHANCED LJ1K5• LEAK DETEC 1 ION (ELD) MiJST BE PERFORMED. PERIODIC ELD IS PERFORMED EVERY 36 MONTHS AS REQUIRED. (23_CCR §ZW-1) ❑ 2. SECONDARY CONTAINMENT COMPONENTS ARE TESTED EVERY 36 MONTHS 4-.K", 3. SPILL BUCKETS ARE TESTED ANNLJALLV. 4'W,2 VIII. RECORDKEEPING The following monitoring/maintenance records are kept for this facility: ❑ Alarm logs 4'xm;xa ❑ Visual Inspection,Records 490-6ain ❑ Tank integrity testing results 4199-6& ❑ SIR testing results (and supporting documentation rocords). 4111ad ❑ Tank gauging results (and supporting documentation records). 4a: -(4k ❑ ATG Testing results (and supporting documentation records). -w-rsr ❑ Corrosion Protection 60 -day logs 41+445 ❑ L-quipmem maintenance and calibration records. 4,Ai-61:, IX. TRAINING Og Personnel with UST monitoring responsibilities are familiar with all of the following documents relevant to their job duties. 4%-69a REFERENCE DOCUMENTS MAINTAINED AT FACILITY (Check all thatapply) 59 THIS UNDERGROUND STORAGE TANK MONITORING PLAN (Required) 49u-r1b +� OPERATING MANUALS FOR ELECTRONIC MONITORING EQUIPMENT (Requiredi490-0je ❑ CALIFORNIA UNDERGROUND STORAGE TANK REGULATIONS 490-69d Q CALTFORNTA UNDERGROUND STORAGE TANK LAW 4ro.:x ❑ STATE WATER RESOURCES CONTROL BOARD (SWRCB) PUBLICATION: "HANDBOOK FOR TANK OWNERS - MANUAL AND STATISTICAL INVENTORY RECONCILIATION" 4:v t9r ❑ SWRCB PUBLICATION: "UNDERSTANDING AUTOMATIC TANK GAUGING SYSTEMS" 4%14% ❑ OTHER (Specity): moiih, moii _ This facility has a "Designated UST Operator" who has passed the California UST System Operator Exam administered by the International Code Council (ICC). The "Designated UST Operator- will train facility employees in the proper operation and maintenance of the UST systems annually, and within 30 days of hire. This training will include, but is not limited to, the following: Operation of the UST systems in a manner consistent with the facility's best management practices > The facility employee's role with regard to the monitoring equipment as specified in this UST Monitoring Plan > The facility employee's role with regard to spills and overfills as specified in the UST Response Plan > Names of contact person(s) for emergencies and monitoring alarms. 490-h1 X. COMMENTSIADDITIONAL INFORNJATION Provide additional comments here or indicate how many pages with additional information on specific monitoring procedures are attached to this plan..rxral git.ST Q Ic� Af—' G XI. PERSONNEL RESPONSIBILITIES The UST Owner/Operator is responsible for ensuring that: 1) the daily/routine UST monitoring activities and maintenance of UST leak detection equipment covered by this plan occurs. 2) all conditions that indicate a possible release are investigated, and 3) all monitoring records are maintained properly. The following persons) are responsible for performing the monitoring and equipment maintenance NAME L +J4ri W . vFr -%i,72 TT ME 0LAreibl Z 4'x)•73 NAME t L-zj?--L -•ma4 TITLE hi 4xI_75 The Designated Operator shall perform a mor.lhly visual inspection of the facility, provide a report to the ownedoperator. and inform the owner'operator of any conditions that need :ollow-up action. XII.OWNER/OPERATOR SIGNATURE CERTIFICATION: I certify that the information provided herein is true and accurate to the best of my knowledge. APP LT ANT SIGNATURE 491.16 DATE: 4•xi-n REPEL ESE1TIl\(i O I Tan. O«ntr10nrrMor � 1 Fnciliiti rh�nerfOacralor ❑ 3. AA0&i. ' ReomsrntaeiV•eaf_pancr 4 » APPLICANT TITLE: APPLICANT NAME (print): 4�..rs / il/11 N d N G +� _ ._ - UPCF UST -D (12/20n, 313 C'd LOEZ-9917-60Z 101AA eOUEUMe� dZV:90 60 6Z Ue