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f LLINIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK MONITORING PLAN- I of TYPE OF ACTION ❑1.NEW PLAN ❑ 2.CHANGE OF INFORMATION 490 1 PLAN TYPE PL 1.MONITORING IS IDENTICAL FOR ALL USTs AT THIS FACIL 490.2 (Check one ttem only) 2.THIS PLAN COVERS ONLY THE FOLLOWING UST SYSTE i I. FACHM, INWRMATION FACILITY ID 0(Agency Use OW - 1 BUSINESS NAME(Same as FACILITY NAME) 3. BUSINESS SITE ADDRESS L 103' CITY 104. II.EQMnU=TESTING AM PRE VE MAINTENANCE Testing,preventive mainimm,and calibration of monitoring equipment(e.g.,sensors,probes,line leek detectors,etc.)must be performted at the frequency specified by the equipment hart ,or annually,whichever is more frequent,and that such work must be performed by qualified personnel. 23 CCR 12§312634,2639,2641 MONITORING EQUIPMENT IS SERVICED .ANNUALLY [199.OTHER(Specify): 4W3b III. LOCATIONS ❑L NEW SITE PLOT PLAN/MAP SUBMITTED WITH THIS PLAN. 13 2.SITE PLOT PLAN/MAP PREVIOUSLY SUBMITTED. (23 CCR§2634 263figM IV.TANK MONIT011ING IS PMFORMW USING TIM!!!U0WING OD(S): i.CONTINUOUS ELECTRONIC TANK MONITORING OF AN )SPACE(S)OR SECONDARY CONTAINMENT 490.5 VAULT(S)WITH AUDIBLE AND VISU (23 CCR§2632,2634) SECONDARY CONTAINMENT IS: A&DRY ❑ b.LIQUID FILLED ❑ c.PRESSURIZED ❑d.UNDER VACUUM 4906 PANEL MANUFACTURER: 490.3. MODEL#: 49M LEAK SENSOR MANUFACTURER: o 490A. MODEL $: 49010 Ij 2,AUTOMATIC TANK GAUGING(ATG)SYSTEM USED TO MONITOR SINGLE WALL TANIU (23 CCR§2643) 490-11 PANEL MANUFACTURER: 490.12 MODEL#: 490-13 IN-TANK PROBE MANUFACTURER: 490.14. MODEL#(S: 490.15 LEAK TEST FREQUENCY: ❑ a.CONTINUOUS ❑ b.DAILYMIGHTLY ❑ c.WEEKLY 490.16 [Id.MONTHLY E3e.OTHERS 490-17 490-18 PROGRAMMED TESTS: ❑ a.0.1 g.p h. [3b.0.2 g.p.h. ❑ c.OTHER(Specify): 490.1'9 ❑ 3.MONTHLY STATISTICAL INVENTORY RECONCILIATION(23 CCR 1): 490-20 ❑ 4.WEEKLY MANUAL TANK GAUGING(hm)(23 CCR§2645). TESTING PERIOD: ❑ a.36 HOURS ❑ b.60 HOURS 4901-21 490.22 5.TANK INTEGRITY TESTING(23 CCR§2643.1): 490-23 TEST FREQUENCY: a.ANNUALLY [3b.BIENNIALLY [Ic.OTHER(Specify): 490.24 a90•u ❑99.OTHER (Spey). 490.26 490-27 V.PEPE MONITORING IS PERFORMED USING THE FOLLOWINGMETHOD(S)(Check all that apply) NEI.CONTINUOUS MONITORING OF PIPE/PIPING SUM")AND OTHER SECONDARY CONTAINMENT WITH AUDIBLE AND 49028 VISUAL ALARM. (23 CCR 12636) SECONDARY CONTAINMENT IS: a.DRY ❑b.LIQUID FILLED ❑c.PRESSURIZED ❑d.UNDER VACUUM 490-29 PANEL MANUFACTURER 490'30 MODEL#:' 49x31 LEAK SENSOR MANUFACTURER: 490 32 MODEL#S): 49x33 PIPING LEAK ALARM TRIGGERS AUTOMATIC PUMP(i.e.,TURBINE)SHUTDOWN. JK&YES ❑b.NO 434 FAILUREIDISCONNECTION OF THE MONITORING SYSTEM TRIGGERS AUTOMATIC PUMP SHUTDOWN. ff,YES ❑b.NO 490.35 2.MECHANICAL LINE LEAK DETECTOR.(MLLD)THAT ROUTINELY RMS 3.0 go.LEAK TESTS AND RESTRICTS OR SHUTS OFF' PRODUCT FLOW A LEAK 18 DE CTED 23 CCR 490-36 MILD MANUFA S: ® r� 490'37 MODEL#(S): - 1000= ❑ 3.ELECTRONIC LINE LEAK DETECTOR(ELLD)THAT RO LY PERFORM 3.0"JL LEAK TESTS(23 CCR§2636) 49x39 ELLD MANUFACTURER(S) 4 . MODEL#L : 490'41 PROGRAMMED IN LINE LEAK TEST. [] 1.MINIMUM MONTHLY 0.2 g.p.h. ❑ 2.MIND"ANNUAL 0.1 g.p.h. 49"2 ELLD DETECTION OF A PIPING LEAK TRIGGERS AUTOMATIC PUMP SHUTDOWN. ❑a.YES ❑b.NO 490.43 ELLD FAILURE/DISCONNECTION TRIGGERS AUTOMATIC PUMP SHUTDOWN. .❑a.YES ❑b.NO 49044 4.PIPE INTEGRITY TE TING 498.0-5 TEST a.ANNUALLY 0 b.EVERY 3 YEARS Ej c.OTHERS 490-46490-47 5.VISUAL PIPE MoNnFoRiNG. 490-4-9- FREQUENCY ❑ a.DAILY ❑ b.WEEKLY ❑c.MIN.MM4THLY A EACH TIME SYSTEM OPERATED' 490.49 ° far MOWMift pr fiml ghft OWY RE HSC IMLI@M ❑ 6.SUCTION PIPING MEETS ExEmPTIoN aunmA 123 CCR§2536(a)(3)1. 49x50 7.NO REGULATED PIPING PER HEALTH AND SAFETY CODE,DIVISION 20,CHAPTER 6.7 IS CONNECTED TO THE TANK SYSTEM 490.51 ❑ 99.OTHER(Specify) 490.52 490-53 UPCF UST-D(12/2007)1/4