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® UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK a MONITORING PLAN--(Page I of 2) TYPE OF ACTION ❑1.NEW PLAN 2.CHANGE OF INFORMATION 490-1 PLAN TYPE ❑ 1.MONITORING IS IDENTICAL FOR ALL USTs AT THIS FACILITY. 490-2 Check one item only) 2.THIS PLAN COVERS ONLY THE FOLLOWING UST SYSTEM( TAN KS 1, 2,3 I. FACILITY:INFORMATION. . FACILITY ID#(Agency Use Only) - - I I I I I I ;.i BUSINESS NAME(Same as FACILITY NAME) COSTCO GASOLINE (LOC. NO. 1091) 3. BUSINESS SITE ADDRESS 2680 REYNOLDS RANCH PARKWAY 103. CITY LODI 104. II.::EQUIPMgNT TESTING AND.Pi2EVENTNE MAINTENANCE Testing,preventive maintenance,and calibration of monitoring equipment(e.g.,sensors,probes,line leak detectors,etc.)must be performed at the frequency specified by the equipment manufacturers'instructions,or annually,whichever is more frequent,and that such work must be performed by qualified personnel. 23 CCR2632?2634263. 8a2641� EQUIPMENT IS SERVICED 1.ANNUALLY ❑ 99.OTHER490-3b MONITORING E Q (Specify): 440.3b III..MQN QRING LO.CAT14N$ ELNEW SITE PLOT PLAN/MAP SUBMITTED WITH THIS PLAN. ❑2.SITE PLOT PLAN/MAP PREVIOUSLY SUBMITTED. (23 CCR§2632, 2634)49o-4 qg� �7��i�A,� 7�� T p�7�rl�•�Thi L� T!� 7��E�1 Et �..,T... �+j �.�1i T[��7[)�i�T�+ 1�r ICS ri [ t:C1.1�6iT.t!i®t7la®Av1,R 4.T At7 J4RL,'4BRE�1[�1}iJ it\G 1I1 i:i VA.iiJ.U9.F 9'Y Altt.,s METJ[A®J,/EO) ..'.. 1.CONTINUOUS ELECTRONIC TANK MONITORING OF ANNULAR(INTERSTITIAL)SPACES)OR SECONDARY CONTAINMENT 49M VAULT(S)WITH AUDIBLE AND VISUAL ALARMS. (23 CCR§2632,2634) SECONDARY CONTAINMENT IS: ❑ a.DRY M b.LIQUID FILLED ❑ c.PRESSURIZED ❑d.UNDER VACUUM 49" - PANEL MANUFACTURER: Veeder-Root 490-7. MODEL#:TLS-35OR 490-8 LEAK SENSOR MANUFACTURER:Veeder-Root 490-9' MODEL AS):794380-301 W 490-10 ❑ 2.AUTOMATIC TANK GAUGING(ATG)SYSTEM USED TO MONITOR SINGLE WALL TANK(S).(23 CCR§2643) 490.11 PANEL MANUFACTURER: 490-12. MODEL#: 49043 IN-TANK PROBE MANUFACTURER- 490-14. MODEL#(S): - 4901 s LEAK TEST FREQUENCY: ❑ a.CONTINUOUS I] b.DAILY/NIGHTLY ❑ c.WEEKLY 490.16 _..- --.... AW.R... .... ... __._...._._._❑.d:...MONTHLY...... ❑-e OTHERS eif):.... PROGRAMMED TESTS: ❑ a.0.1 h.� _ ❑ b.0.2 h. ❑ c.OTHER490-18 $•p• g•P• (Specify): 09019 ❑ 3.MONTHLY STATISTICAL]INVENTORY RECONCILIATION(23 CCR§2646.1): 490-20 ❑ 4.WEEKLY MANUAL TANK GAUGING(MTG)(23 CCR§2645). TESTING PERIOD: E] a.36 HOURS [Ib.60 HOURS y�22 5.TANK INTEGRITY TESTING(23 CCR§2643.1): 490-23 TEST FREQ UENCY: ❑ a.ANNUALLY [Ib. c.BIENNIALLY ❑ OTHER( p �)� 490-2S(Specify): 490-25 5 ❑ 99.OTHER (Specify): 490-26 490-27 Y..PIPE M®NITORING:IS PERFORMED..USING TIIE FOIL®WING 1VIMETIIQD(S)_(ChCck.all that aPpIY} 1.CONTINUOUS MONITORING OF PIPE/PIPING SUMP(S)AND OTHER SECONDARY CONTAINMENT WITH AUDIBLE AND 490-28 VISUAL ALARMS. (23 CCR§2636) SECONDARY CONTAINMENT IS:❑a.DRY Eb.LIQUID FILLED ❑c.PRESSURIZED Ed.UNDER VACU_U_M490.29 PANEL MANUFACTURER: Ve2der-RODS 490-30 t MODEL#:TLS-_35OR 431 LEAK SENSOR MANUFACTURER:Veeder-Root 490 32 MODEL#(S): 794380-208,794384-304 M 490-33 PIPING LEAK ALARM TRIGGERS AUTOMATIC PUMP(i.e.,TURBINE)SHUTDOWN. N a.YES ❑b.NO -T 49034 FAILUREIDISCONNECTION OF THE MONITORING SYSTEM TRIGGERS AUTOMATIC PUMP SHUTDOWN. 0 a.YES ❑b.NO 490-35 2.MECHANICAL LINE LEAK DETECTOR(MLLD)THAT ROUTINELY PERFORMS 3.0 g p.h.LEAK TESTS AND RESTRICTS OR SHUTS OFF PRODUCT FLOW WHEN A LEAK IS DETECTED 23 CCR§263@ 490-36 MLLD MANUFACTURER(S): PE Petro 49037 MODEL#(S): STP-MLD-D 490-38 3.ELECTRONIC LINE LEAK DETECTOR(ELLD)THAT ROUTINELY PERFORMS 3.0 g p.h.LEAK TESTS (23 CCR§2636) 490-39 _ ELLD MANUFACTURER(S)Veeder-Root 490.40. MODEL#(S): -480-- 1 490.41 PROGRAMMED IN LINE LEAK TEST: 0 1.MINIMUM MONTHLY 0.2 g.p.h. 2.MINIMUM ANNUAL 0.1 g.p.h. 490 0-2 FLLD DETECTION OF A PIPING LEAK TRIGGERS AUTOMATIC PUMP SHUTDOWN. a.YES ❑b.NO 490.43 ELLD FAILUREIDISCONNECTION TRIGGERS AUTOMATIC PUMP SHUTDOWN. a.YES ❑b.NO 49044 4.PIPE INTEGRITY TESTING 49o-4s TEST FRE UENCY0 a.ANNUALLY ❑ b.EVERY 3 YEARS ❑ c.OTHER(Specify) 490-46490.47 5.VISUAL PIPE MONITORING. 490-48 FREQUENCY ❑ a.DAILY ❑ b.WEEKLY ❑c.MIN.MONTHLY&EACH TIME SYSTEM OPERATED* 490-49 *Mowed for monftoamg of unburied em ency genamtor fuel piping only per HSC 125281.5(b)(3) ❑ 6.SUCTION PIPING MEETS EXEMPTION CRI'T'ERIA 123 CCR§2636(a)(3)]. 490-50 ❑ 7.NO REGULATED PIPING PER HEALTH AND SAFETY CODE,DIVISION 20,CHAPTER 6.7 IS CONNECTED TO THE TANK SYSTEM 490-5t El99.OTHER(Specify) 490.52 49Q-53 UPCF UST-D(12/2007)114 14573-F-ADPL-TANK PERM...Revised-2012.09-20.pdf