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UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK MONITORING PLAN-(Page I of 2) TYPE OF ACTION ❑1.NEW PLAN .CHANGE OF INFORMATION 490"1 PLAN TYPE ❑ t.MONITORING IS IDENTICAL FOR ALL USTs AT THIS FACILITY. 490.2 (Check one item only) ❑ 2.THIS PLAN COVERS ONLY THE FOLLOWING UST SYSTEM(S)- 1. FACILITY INFORMATION FACILITY ID#(Agency Use Only) - I BUSINESS NAME(Same as FACILITY NAME) 3. BUSINESS SITE ADDRESS ; 1°3_ CITY ® 104. IL EQUIPMENT TESTING AND PREVENTIVE MAINTENANCE Testing,preventive maintenance,and calibration of monitoring equipment(e.g.,sensors,probes,line leak detectors,etc.)must be perforated 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 EQUIPMENT IS SERVICED .ANNUALLY ❑ 99.OTHERS 49x3° MONITORING E Q (Specify): 190.517 III.MONITORING LOCATIONS NEW SITE PLOT PLAN/MAP SUBMITTED WITH THIS PLA OT PLAN/MAP PREVIOUSLY SUBMITTED. (23 CCR§2632, 2634 vaa IV.TANK MONITORING IS PERFORMED USING T11E FOLLOWING METHOD(S): 1p,l.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 MANUFACTURER0,/ 490.7' MODEL#: 4918 LEAK SENSOR MANUFA 4919. MODEL#(S): 0-9110 2.AUTOMATIC TANK GAUGINGTEM USED TO MONITOR SINGLE WALL TANK/S).(23 CCR§2643) 490-11 PANEL MANUFACTURER: 49112 MODEL#: 490-13 IN-TANK PROBE MANUFACTURER: 114. MODEL#(S): 490-15 LEAK TEST FREQUENCY: ❑ a.CONTINUOUS ❑ b.DAILY/NIGHTLY ❑ c.WEEKLY 49116 ❑ d.MONTHLY ❑ e.OTHER(Specify): 49117 PROGRAMMED TESTS: ❑ a.0.1 h. ❑ b.0.2 h. ❑ c.OTHERS I ): 49119 g•P• g•P• ( P��fY 190.19 ❑ 3.MONTHLY STATISTICAL INVENTORY RECONCILIATION(23 CCR§2646.1): 490'20 ❑ 4.WEEKLY MANUAL TANK GAUGING(MTG)(23 CCR§2645). TESTING PERIOD: ❑ a.36 HOURS ❑ b.60 HOURS 49D-21 19012 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 MONITORING IS PERFORMED USING THE FOLLOWINGMETHOD(S)(Check all that apply) 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 ❑b.LIQUID FILLED ❑c.PRESSURIZED ❑d.UNDER VACUUM 490-29 PANEL MANUFACTURER S1 tag ry BWE 49°30 MODEL#: 490-31 LEAK SENSOR MANUFACTURER: 490-32 ' 490-33 PIPING LEAK ALARM TRIGGERS AUTOMATIC PUMP(i.e.,TURBINE)SHUTDOWN. ❑a.YES ❑b.NO 490-34 FAILURE/DISCONNECTION OF THE MONITORING SYSTEM TRIGGERS AUTOMATIC PUMP SHUTDOWN. ❑a.YES ❑b.NO 490.35 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 490.36 MLLD MANUFACTURER(S): 49037 MODEL#(S): 8 ❑ 3.ELECTRONIC LINE LEAK DETECTOR(ELLD)THAT ROUTINELY PERFORMS 3.0 g.p h.LEAK TESTS (23 CCR§263 ) 490.39 ELLD MANUFACTURER(S) 490'40' 1 MODEL#(S): 49141 PROGRAMMED IN LINE LEAK TEST: ❑ 1.MINIMUM MONTHLY 0.2 g.p.h. ❑ 2.MINIMUM ANNUAL 0.t g.p.h. 4 +42 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 TESTING 490-45 TEST FREQUENCY 0 a.ANNUALLY 0 b.EVERY 3 YEARS c.OTHER(SREifyj 490-46490-07 El 5.VISUAL PIPE MONITORING. 490-48 FREQUENCY ❑ a.DAILY ❑ b.WEEKLY ❑C.MIN.MONTHLY&EACH TIME SYSTEM OPERATED` 490-49 ®Allowed for nionitonngofuninmed entalgeacy awraw fuel pipag only HSC§25291.5(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) 19152 190-53 UPCF UST-D(1