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COMPLIANCE INFO_1997-2012
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PR0231333
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COMPLIANCE INFO_1997-2012
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Last modified
9/24/2024 2:31:42 PM
Creation date
6/3/2020 9:46:41 AM
Metadata
Fields
Template:
EHD - Public
ProgramCode
2300 - Underground Storage Tank Program
File Section
COMPLIANCE INFO
FileName_PostFix
1997-2012
RECORD_ID
PR0231333
PE
2361
FACILITY_ID
FA0003711
FACILITY_NAME
LAKEWOOD CHEVRON
STREET_NUMBER
236
Direction
N
STREET_NAME
HAM
STREET_TYPE
LN
City
LODI
Zip
95240
APN
03710028
CURRENT_STATUS
01
SITE_LOCATION
236 N HAM LN
P_LOCATION
02
P_DISTRICT
004
QC Status
Approved
Scanner
SJGOV\rtan
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FilePath
\MIGRATIONS\UST\UST_2361_PR0231333_236 N HAM_1997-2012.tif
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EHD - Public
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e <br /> ILI <br /> (Agency Use Only) Thi Ian has been re 'wed IpApproverl ā¯‘Approved With Conditions <br /> Local Agency Signature: Date: <br /> Comments or Special Conditi <br /> UST Monitoring Plan-Page 2 Instructions <br /> Complete a separate UST Monitoring Plan for each UST monitoring system at the facility. This form must be submitted with your initial UST <br /> Operating Permit Application and within 30 days of changes in the information it contains. Please note that your local agency may require you to <br /> obtain approval prior to installing or modifying monitoring equipment. (Note: Numbering of these instructions follows the data element numbers on <br /> the form.) <br /> 490-54a.MONITORING OF THE UNDER DISPENSER CONTAINMENT-Indicate the method used for UDC monitoring. <br /> 490-54b.SPECIFY-If 99"Other"is checked,describe other method used. <br /> If VI-1-1,VI-1-2 or VI-1-3 or VI-1-99 is checked,complete 490-55 to 490-64b. <br /> 490-55. PANEL MANUFACTURER-Enter the name of the manufacturer of the monitoring system control panel(console). If there is no control panel(e.g.,only an electrical <br /> relay box is installed)leave this space blank. <br /> 490-56. MODEL#- Enter the model number for the monitoring system control panel(console).If there is no control panel(e.g.,only an electrical relay box is installed)leave <br /> this <br /> space blank. <br /> 490-57. LEAK SENSOR MANUFACTURER-Enter the name of the manufacturer of the sensor(s). <br /> 490-58. MODEL#(S)-Enter the model number of the sensor(s)installed.If additional space is needed,use Section X. <br /> 490-59. DETECTION OF A LEAK INTO THE UDC TRIGGERS AUDIBLE AND VISUAL ALARMS. Indicate Yes or No <br /> 490-60. UDC LEAK ALARM TRIGGERS PUMP SHUTDOWN- Indicate Yes or No <br /> 490-61. FAILURE/DISCONNECTION OF UDC MONITORING SYSTEM TRIGGERS AUTOMATIC PUMP SHUTDOWN-Indicate Yes or No <br /> 490-62. UDC MONITORING STOPS THE FLOW OF PRODUCT AT THE DISPENSER-Indicate Yes or No. <br /> 490-63. UDC CONSTRUCTION- Indicate if the construction of the UDC is single-walled,or double-walled. <br /> 490-64a.DOUBLE-WALLED INTERSTITIAL SPACE MONITORING- Indicate what is used to monitor the interstitial space. <br /> 490-64b.LEAK WITHIN THE SECONDARY CONTAIMENT OF UDC TRIGGERS AUDIBLE AND VISUAL ALARMS-Indicate Yes or No <br /> 490-65. VII-1 ELD TESTING-Check the box if you have been notified by the State Water Resources Control Board(SWRCB)that the UST(s)covered by this plan is/are <br /> subject to Enhanced Leak Detection Requirements(i.e.,UST has any single-wall component and is located within 1,000 feet of a public drinking water well). <br /> 490-66. TESTING OF SECONDARY CONTAINMENT COMPONENTS EVERY 36 MONTHS-Check the box if you have secondary containment that requires testing. <br /> 490-67. SPILL BUCKET TESTING-Check the box if you have spill buckets. <br /> 490-68a-h.VIII RECORDKEEPING-Indicate which monitoring and equipment maintenance records are maintained for this facility. <br /> 490-69a IX TRAINING STATEMENT-Check the box to verify that the statement is true. <br /> REFERENCE DOCUMENTS MAINTAINED AT FACILITY-Check the appropriate boxes to describe reference documents maintained at the facility. Note that the <br /> first two items on the list must be kept at the facility. <br /> 490-69b. MONITORING PLAN:Indicate that this plan is kept as a reference document. <br /> 490-69c. OPERATING MANUALS FOR ELECTRONIC EQUIPMENT:Indicate that this plan is kept as a reference document. <br /> 490-69d. CA UST REGULATIONS-Indicate that this is kept as a reference document. <br /> 490-69e. CA UST LAW-Indicate that this is kept as a reference document. <br /> 490-69f.STATE WATER RESOURCES CONTROL BOARD(SWRCB)PUBLICATION- "HANDBOOK FOR TANK OWNERS-MANUAL AND <br /> STATISTICAL INVENTORY RECONCILIATION-Indicate that this is kept as a reference document. <br /> 490-69g.SWRCB PUBLICATION:"UNDERSTANDING AUTOMATIC TANK GAUGING SYSTEMS":Indicate that this is kept as a reference document. <br /> 490-69h.OTHER-Indicate that other reference documents are kept. <br /> 490-69i. SPECIFY-If"OTHER"is checked,enter a brief description of the other document(s)maintained at the facility.If additional space is needed,see Section X. <br /> 490-70, DESIGNATED OPERATOR TRAINING-Check this box to verify that this statement is true. <br /> 490-71. COMMENTS/ADDITIONAL INFORMATION-Make additional comments or you may attach and identify the number of additional pages of information to describe <br /> any additional UST system monitoring-related information(e.g.,additional information required by your local agency). Attach any monitoring logs that you will be using <br /> for the monitoring of your tank system. <br /> 490-72. NAME-Enter the name of the person who routinely conducts the monitoring and equipment maintenance under this plan. <br /> 490-73. TITLE- Enter the title of the person. <br /> 490-74. NAME-Enter the name of the second person,if applicable,who routinely conducts the monitoring and equipment maintenance under this plan. <br /> 490-75. TITLE- Enter the title of the second person. <br /> OWNER/OPERATOR SIGNATURE-The tank owner/operator,facility owner/operator,or an authorized representative of the owner shall sign in the space provided. <br /> This signature certifies that the signer believes that all information submitted is true,accurate,and complete,and that the training program specified in Section IX has <br /> been implemented. <br /> 490-76. REPRESENTING--Check the appropriate box to indicate whether the signer is the UST owner/operator,the UST facility owner/operator,or an <br /> authorized representative of the owner. <br /> 490-77. DATE-Enter the date the plan was signed. <br /> 490-78. APPLICANT NAME-Print or type the name of the person signing the plan. <br /> 490-79. APPLICANT TITLE-Enter the title of the person signing the plan. <br /> UPCF UST-D(12/2007)414 <br />
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