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UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK MONITORING PLAN- (Page 2 of 2) VIXND +'R DISPENSER CONTAINMENT(UD(.")MONITORING (�h�ckall UDC MONITORING IS PERFORMED USING THE FOLLOWING METHOD(S) ❑ 1.CONTINUOUS ELECTRONIC MONITORING 2.FLOAT AND CHAIN ASSEMBLY ❑ 3.ELECTRONIC STAND-ALONE 490-54a_ ❑ 4.NO DISPENSERS __....._-...._..__._.....__. 99.OTHER(Specify) 490-54b. _... ......._.._ ..---............-_..............--...........-................._._._...._....� LEAK MONITOR MANUFACTURER: 4910-55. MODEL#: LEAK SENSOR MANUFACTURER: 490-57. MODEL#(S): 490-58. DETECTION OF A LEAK INTO THE UDC TRIGGERS AUDIBLE AND VISUAL ALARMS. ❑ a.YES 20 b.NO 490-59. UDC LEAK ALARM TRIGGERS AUTOMATIC PUMP SHUTDOWN. ❑ a.YES IN b.NO 490-60, FAILURE/DISCONNECTION OF UDC MONITORING SYSTEM TRIGGERS AUTOMATIC PUMP SHUTDOWN. [1 a.YES 9 b.NO 490-61. UDC MONITORING STOPS THE FLOW OF PRODUCT AT THE DISPENSER. 9 a.YES ❑ b.NO 490-62. _............._._...........-_....._..-..........._.........._.._.�...._.._..........._._. ........._..._.................-..._.........._.-............-_._......_..._...._..........-_._...._.._...._....__...- .......---............._..........._....-.................-..............__............_...--.._-.- UDC CONSTRUCTION IS: L SINGLE WALL E] 2.DOUBLE WALL 49063. -63. IF DOUBLE WALL: 490-64a UDC INTERSTITIAL SPACE IS MONITORED BY: ❑ a.LIQUID ❑ b.PRESSURE ❑ c.VACUUM A LEAK WITHIN THE SECONDARY CONTAINMENT OF THE UDC TRIGGERS AUDIBLE AND VISUAL ALARMS. ❑ a.YES ❑ b.NO 490-64b. _ VII. PERIODIC SYSTEM TESTING. ❑ 1.ELD TESTING: THIS FACILITY HAS BEEN NOTIFIED BY THE STATE WATER RESOURCES CONTROL BOARD THAT ENHANCED 490-65. LEAK DETECTION ELD MUST BE PERFORMED. PERIODIC ELD IS PERFORMED EVERY 36 MONTHS AS REQUIRED.123 CCR 82644.11 ® 2.SECONDARY CONTAINMENT COMPONENTS ARE TESTED EVERY 36 MONTHS. ago-66. ® 3.SPILL BUCKETS ARE TESTED ANNUALLY. 490-67. Y, VIII. 'RECORD KEEPING The following monitoring/maintenance records are kept for this facility: 490-68. ® a.ALARM LOGS ❑ b.VISUAL INSPECTION RECORDS ❑ c.TANK INTEGRITY TESTING RESULTS ❑ d.SIR TESTING RESULTS(and supporting documentation records) ❑ e.TANK GAUGING RESULTS(and supporting documentation records) ❑ f.ATG TESTING RESULTS(and supporting documentation records) ❑ g.CORROSION PROTECTION 60-DAY LOGS ® h.EQUIPMENT MAINTENANCE AND CALIBRATION RECORDS IX. TRAINING ®/Personnel with UST monitoring responsibilities are familiar with all of the following documents relevant to their job duties: 490-69a REFERENCE DOCUMENTS MAINTAINED AT FACILITY(Check all that apply) ® THIS UNDERGROUND STORAGE TANK MONITORING PLAN(Required) 490-69b. ® OPERATING MANUALS FOR ELECTRONIC MONITORING EQUIPMENT(Required) 490-69c. ❑ CALIFORNIA UNDERGROUND STORAGE TANK REGULATIONS 490-69d ❑ CALIFORNIA UNDERGROUND STORAGE TANK LAW 490-69e. ❑ STATE WATER RESOURCES CONTROL BOARD (SWRCB) PUBLICATION: "HANDBOOK FOR TANK OWNERS - MANUAL AND 490-69f. STATISTICAL INVENTORY RECONCILIATION" ❑ SWRCB PUBLICATION:"UNDERSTANDING AUTOMATIC TANK GAUGING SYSTEMS" 490-698. 490-69h. ❑ OTHER(Specify): 490-69i. ® This facility has a"Designated UST Operator"who has passed the California UST System Operator Exam administered by the International Code Council 490-70. (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 facility's UST Response Plan. ➢ Name(s)of contact person(s)for emergencies and monitoring alarms. X. COMMENTS/ADDITIONAL INFORMATION Provide additional comments here or indicate how many pages with additional information on specific monitoring procedures are attached to this plan. 490-71. 777777777 7I. 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 thislan occurs;2 fall conditions that indicate apossible release aze investi.gated;and 3.)all monitories records are maintained properly. __ _.___-__._._, _ THE FOLLOWING PERSON(S)ARE RESPONSIBLE FOR PERFORMING THE MONITORING AND EQUIPMENT MAINTENANCE: NAME: 490.72. TITLE: 490-73. NAME: 490-74. TITLE: 490-75. The Designated UST Operator shall perform a monthly visual inspection of the facility,provide a report to the owner/operator,and inform the owner/operator of any conditions that need follow-u action. RYL OWNER/OPERATOR SIGNATURE CERTIFICATION:I certify that the information provided herein is true and accurate to the best of my knowledge. APPLICANT SIGNATURE DATE: 490-77. REPRESENTING:❑1.Tank Omer/Operator 2.Facility 0"er/operator❑3.Authorized Re resentative of Owner 490.76. APPLICANT NAME(print): 490-78. APPLICANT TITLE: 490-79. UPCF UST-D(12/2007)-3/4 www.unidocs.org