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UN[FUD PROGRAM CONSOUDATED FORM UNDEItGROUNDSTORAGETANK MONITORING PLAN-(Page 2 of 2} (Check all VI.UNDER DISPENSER CONTAINMENT(uDc)moNrrORING that a0910 UDC MONITORING IS PERFORMED USING THE FOLLOWING METHOD(S) 490-54a. I CONTINUOUS ELECTRONIC MONITORING 0 2.FLOAT AND CHAIN ASSEMBLY 0 3.ELECTRONIC STAND-ALONE 490-54b El 4.NO DISPENSERS [] 99.OTHER(Specify) 490-56. LEAK MONITOR MANUFACTURER i2fit-r - 490-". MODEL#: -T-1-S *3 SV_ LEAK SE14SOR MANUFACTURER: &XH& 490-57- MODEL#(S)--7c?(4.3 TO Zt 490-58. DETECTION OF A LEAK INTO THE UDC TRIGGERS AUDIBLE AND VISUAL ALARMS. YES 0 b.NO 49D-39. R . UDC LEAK ALARM TRIGGERS AUTOMATIC PUMP SHUTDOWN. aYES ❑ b.NO 490-60 FAILUREIDISCONNECTION OF UDC MONITORING SYSTEM TRIGGERS AUTOMATIC PUMP SHUTDOWN. FD a.YES ❑ b.NO UDC MONITORING STOPS THE FLOW OF PRODUCT AT THE DISPENSER- a.YES ❑ b.NO 490 62 UDC CONSTRUCTION IS: 1.SINGLE WALL ❑ 2.DOUBLE WALL 490.63. 490-64& IF DOUBLE WALL UDC INTERSTITIAL SPACE IS MONITORED BY: [I a.LIQUID ❑ b.PRESSURE [1c.VACUUM A LEAK WITHIN THE SECONDARY CONTAINMENT OF THE UDC TRIGGERS AUDIBLE AND VISUAL ALARMS. 0 &YES D &NO 49"4' VM PERIODIC SYSTEM TES 1.ELD TESTING:THIS FACILITY HAS BEEN NOTIFIED BY THE STATE WATER RESOURCES CONTROL BOARD THAT ENHANCED 49ae3. LEAK DETECTIOWA&W-MUST BE PERFORMED. PERIODIC ELD IS PERFORMED EVERY 36 MONTHS AS REQUIRED.123 ccR§2644.11 490-66. 2.SECONDARY CONTAINMENT COMPONENTS ARE TESTED EVERY 36 MONTHS. 490.67. 3.SPILL BUCKETS ARE TESTED ANNUALLY. VIII. RECORD]KEEPING The following monitoringlinaintenance:records are kept for this facility: 490-68. 0 a-ALARM LOGS 0 b-VISUAL INSPECTION RECORDS ❑ c.TANK INTEGRITY TESTING RESULTS 0 d.SIR TESTING RESULTS(mid supporting documentation records) ❑ e.TANK GAUGING RESULTS(and SUPPOrtIng d0cuircoMm=Olds) 0 f.ATG TESTING RESULTS(and supporting documentation records) 0 g.CORROSION PROTECTION 60-DAY LOGS 0 IL E2UIPMENT MAINTENANCE AND CALIBRATION RECORDS UL 111AINING 0 Personnel with UST monitoring responsibilities are farmitar with all of following documents relevant to their job duties: 490-69& REFERENCE DOCUMENTS MAINTAINED AT FACILITY(Check all that apply) 49M9b- THIS UNDERGROUND STORAGE TANK MONITORING PLAN(Required) 49049C. OPERATING MANUALS FOR ELECTRONIC MONITORING EQUIPMENT(RequiFem 490-69d. 0 CALIFORNIA UNDERGROUND STORAGE TANK REGULATIONS 490-69e 0 CALIFORNIA UNDERGROUND STORAGE TANK LAW ' 0 STATE WATER RESOURCES CONTROL BOARD (SWRCB) PUBLICATION: -HANDBOOK FOR TANK OWNERS MANUAL AND 490-W STATISTICAL INVENTORY RECONCILIATION" 490-699 ❑ SWRCB PUBLICATION:"UNDERSTANDING AUTOMATIC TANK GAUGING SYSTEMS" 49"9 ❑ OTHER(Specify): 490-69i. This facility has a"Designated UST Operator"who has passeilthe California UST System Operator Exam administered by the international Code Council 490-70 (ICC). The -Designated UST Operator-will train facility employees in the proper operation and maintenance of the UST system annually,and within 30 days of hire.This training will include,but is not limited to,the following: • operation of the UST systems in a manner consistent with the facility's best management practices. 1 1 • The facility employee's role with regard to the monitoring equipment as specified in this UST Monitoring Plan. • The facility employee's role with regard to spills and overfills as specified in the facility's UST Response Plan. • Name(s)of contact person(s)for emergencies and monitoring alarms. X COMMENTS/ADDITIANAL INFORMATION-I' 490-71. ProvideN additional commej Z_L_nes here or indicate how many-r)pajes with additional info r45Rmation on spectfic;monitoring procedures are attached to this plan. FVEN - 4s- J-- 7--owX cAeA CIV V TAX (2 fi-tj " -VA4AK S1,5771* XL PERSONNEL SPANS EL The UST owner/operator is responsible for ensuring that: 1.)thedaily/routme UST monitoring activities and namterance of UST leak detection equipment covered . �y this plan occurs;2.)all conditions that indicate a possible release are investi&gg and 3.)all monitoring records we maintained property. THE FOLLOWING PERSON(S)ARE RESPONSIBLE FOR PERFORMING5 THE MONITORING AND EQUIPMENT MAINTENANCE: 490-73. NAME: A Li 49o-72 TITLE: EAPL,911FE - 490-75. 90.74. TITLE: NAME: e*� MA-kAAL MA WA IL 4 The Designated UST operator shall perform a monthly visual inspection of the facility,provide a report to the owned r,and inform the owner/operator of any conditions that need follow-up action- XII. OVVNER/OPE RATOR SIGNATURE CERTIFICATION:I certify that the information provided herein is true and accurate to the best of my knowledge, 4W77. APPLICANT SIGNATURE DATE, 6-17-OF mpmemwa 0 1,T-*0-wi jzWof 0w= 490.76. 490-79. APPLICANT NAME(print): /Vo APPLICANT TITLE- AIV'r JV F# -5'-4I www.unidocs.org UPCF UST-D(12/Mn-3/4