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UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK MONITORING PLAN- Pae 1 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(C)• TANKS 1, 2, 3 I. FACILITY INFORMATION FACILITY ID#(Agency Use Only) BUSINESS NAME(Same as FACILITY NAME) COSTCO GASOLINE (LOC. NO. 1091) 3.. BUSINESS SITE ADDRESS 2680 REYNOLDS RANCH PARKWAY 103. CITY LODI 104. IL EQUIPMENT TESTING AND PREVENTIVE N CE 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 CCR 2632 2634 2638 2641 MONITORING EQUIPMENT IS SERVICED 1.ANNUALLY ❑ 99.OTHER S u 491-3 ( �fY)• 490-3bb M.MON1TOR1NG WCATIONS I.NEW SITE PLOT PLAN/MAP SUBMITTED WITH THIS PLAN. 2.SITE PLOT PLAN/MAP PREVIOUSLY SUBMITTED. (23 CCR§2632, 2634 %4 IV.TANK MONffOWNG IS PERFORMED USING THE FOLLOWINGMETHOD(S): ® 1.CONTINUOUS ELECTRONIC TANK MONITORING OF ANNULAR(INTERSTITIAL)SPACE(S)OR SECONDARY CONTAINMENT 490-5 VAULT(S)WITH AUDIBLE AND VISUAL ALARMS. (23 CCR§2632,2634) SECONDARY CONTAINMENT IS: ❑ a.DRY ® b.LIQUID FILLED ❑ c.PRESSURIZED ❑d.UNDER VACUUM 490-6 PANEL MANUFACTURER: Veeder-Root " I MODEL#: TLS-350R 4 LEAK SENSOR MANUFACTURER:Veeder-Root 49"" 1 MODEL#(S):794380-301 490-10 2.AUTOMATIC TANK GAUGING(ATG)SYSTEM USED TO MONITOR SINGLE WAU TAMM.(23 CCR§2643) 490-11 PANEL MANUFACTURER: 490-12' MODEL#: 490-13 IN-TANK PROBE MANUFACTURER: 490-f4' MODEL#(S): 490-15 LEAK TEST FREQUENCY: ❑ a.CONTINUOUS ❑ b.DAILY/NIGHTLY ❑ c.WEEKLY 490-16 d.MONTHLY e.OTHERS i 490-17 490-18 PROGRAMMED TESTS: ❑ a.0.1 g.p.h. ❑ b.0.2 g.p.h. ❑ c.OTHER(Specify): 490-19 ❑ 3.MONTHLY STATISTICAL INVENTORY RECONCILIATION(23 CCR§2646.1): 490-20 ❑ 4.WEEKLY MANUAL TANK GAUGING(MTG)(23 CCR§2645). TESTING PERIOD: [:1a.36 HOURS E] b.60 HOURS 490-21 490-22 ❑ 5.TANK INTEGRITY TESTING(23 CCR§2643.1): 490-23 TEST FREQUENCY: ❑ a.ANNUALLY ❑ b.BIENNIALLY ❑ c.OTHER(Specify): 490-24 490-25 99.OTHER (Specify): 490-26 490-27 V.PIPE MON1TORING IS PERFORMED USING THE FOLLOWING OD(S)(Cheek still that apply) 1.CONTINUOUS MONITORING OF PIPE/PIPING SUMP(S)AND OTHER SECONDARY CONTAINMENT WITH AUDIBLE AND 490-29 VISUAL ALARMS. (23 CCR§2636) SECONDARY CONTAINMENT IS:❑a.DRY ®b.LIQUID FILLED ❑c.PRESSURIZED Ed.UNDER VACUUM 490.29 PANEL MANUFACTURER: Veeder-Root a9ta3oMODEL#: TLS-350R 490.31 LEAK SENSOR MANUFACTURER:Veeder-Root 490 3z MODEL#(S): 7 Q-2(>S,794380-304 490.33 PIPING LEAK ALARM TRIGGERS AUTOMATIC PUMP(i.e.,TURBINE)SHUTDOWN. ®a.YES ❑b.NO 490-34 FAILUREIDISCONNECTION OF THE MONITORING SYSTEM TRIGGERS AUTOMATIC PUMP SHUTDOWN. ®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 2 490-36 MLLD MANUFACTURER S): EE Petro 490.37 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 MANUFACTUREMS)Veeder-Root 4�40" MODEL#(S): 49041 PROGRAMMED IN LINE LEAK TEST: 0 1.MINIMUM MONTHLY 0.2 g.p.h. 2.MINIMUM ANNUAL 0.1 g.p.h. 490.42 ELLD 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 490-44 4.PIPE INTEGRITY TESTING 490.49 TEST FREQUENCY ❑ a.ANNUALLY b.EVERY 3 YEARS ❑ c.OTHER(Specify) 490-464 47 ❑ 5.VISUAL PIPE MONITORING. 490-48 FREQUENCY ❑ a.DAILY ❑ b.WEEKLY ❑C.MIN.MONTHLY&EACH TIME SYSTEM OPERATED* 490-49 °Allowed for monito'ng of unburied emergency enerator fuel pipiM only per HSC§25281.5(b)(3) ❑ 6.SUCTION PIPING MEETS EXEMPTION CRITERIA 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 490-51 ❑ 99.OTHER(Specify) 490-52 490-53 UPCF UST-D(12/2007)1/4 14573-F-APPL-TANK PERM...Revised-2012-09-20.pdf