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! 1% is • s '�4�94F1.=�mppa"u7o"ta�• 'i�«�"+N�wr=.'-wh-....- Complete adagef i OSTMonitoring �Me . This form be s wif6 yp� OST Application and widda 30 d In the it �y eagall0 ya.b o $ 490-1. TYPE OF ACTION- the baa m t� is ® of the 490-2. PI.KbiTYPE-Chockthe baa a0.orof the USTs n fhe fh WW. If the plan otdy 'd tanks in the [m&.by T #(s)ID' 432 ofths UST Permitppl A ' -Torok Fon*$)j- 1. FACU=ID - n fa a 3. BUS -Enter the complete Emily Xsew, - 103. BUSINESS SITE ADDRESS- the sued address vAusethe hodity is located.including budding number,ifspplicabta Pon office box acean This a is the �. 104. CITY- the city oran in the is y 490-3a MONITORING EQ IS SERVICED-Chack SERVICED- dwappoolmase boa lospecifytha ftoqmq of': ..- n 490-3b Sservicing. 4904 SIZE if it orifi .a: _ Was submitted ■Sita Plat tbs orad previoasiy end is for the `4 CLa of h leek 3 490.S N-1 CONTINUOUS ELECTRONIC ifft moubcdog method Is used to menuor the tanks.. ' 490.6 SECONDARY CONT -UW-1 is the baa m fUa the talc °b 490-7 A --U1V-1 h the offt off (consde) 490.8 MODEL,#-MIV%h maths fwft 490-9 LEAK SEMR. -MTV-1 is the now offt maeadholewrofthe s).Ifacklitional space is use Section X 490-10 MODEL#(S)--IfIV 1is clocked,amertbe model munberforenchtypeof .Ifuklitional space isnwdKnmsection X 490.11 IV-2 AUTOMATIC TANK GA ffdds method$used fbrmmftftdw UST's 490-12 PANEL MANUFA -U1V-2ta chocked,cuterthe name dfhs menelhoumofthe mougedogsystace comml pod( a� 490-13 MODEL#-UIV 2 is the fba tine 490-14 IN-TANK PROBE MANUF -IfIV 2 is da namofthe auseethoftwofthe probes) 490.15 MODEL#(S)-%fIY 2 ischeckedcondie fa typed ptoba' ed If additional is use Section X - 490-16.LEAK TESTFREQUENCY-UIV-2 g chocked.check the appropuft boa to describe the"m4auk teak ten fiecluency. e. ` 490-17.SPECIFY-U490-16ais chocked.conthefiequencyofIregreasnedleakasts, - 490.18.PROG -IfIV-2 ischocked.chocktheappeoptimg boa t0 dmft the tests prugmenned fift the ATC;systm " 4 490-19.SPECIFY-If 490.13cischockedcomthe d t t :"gam 490.20.IV-3 INVENTORY NCII.%ATION- thaboxifststistical lvemyrtwumliltimisperkumed. " 490.21.IV4 WEEKLY MAN1UAL TANK GAUGINM Indicate ifthk method is medto mwawtbg Wmr, F 490-22 TESTING PERIOD-UIV-4 is checked,check the Wroprinte box dmftdw MM testing period. 490-23.IV S TANK lN1TEGRrrYTEMM halumcifthismethodawed to momartkadm. 490.24.TEST FREQ -U%V S ischackedcbecktheappmproft balm dociftthe ftpmcyfftak&Wgjy ftsft 490-2S.OTHER:-X490-24c is otberum -.._.. 490-26.IV-99 ffmcamornig ofibetanks occurs that a not_indicated- jenny odwcmMy 490-27.MIV-99is checked,cum a briefdoseription ofthe ochertank monitodagmWags)land(&16 vxb_man 'monimung pa23 CCR§2647, par _. 23CCR§2648). Include the (a.16W M la X 490.28. V-1 OUS MONITORING OF p7wlpLNG mAem AND OTHER SBcOb1DARy coNrAnasNT WITH AUDIB LE AND VISUAL : Mom ifthis is this monitoring method and lbrtbs ' ' 490.29.SECA YCONT UWl is clocked,Check the appopria box to describe do envuomwut inside piping secoudery containment. t. 490.30.PANEL.MANUFACTURER-IM1 is checked,caw do name ofdw mgmactaswofthemonitoring munn commi pand( a} 490-31.MODEL#-MV 1 isebeckedamerthemodd tuali if iffbrthemonitoring System mod FOWL ' 490.32.LEAK -MV-1ffi offt d s) 490.33.MODEL#(S)-MV 1 isa=kKc=ftmOMumdwtwcmbtMofnmwkudbe&lfaddkiW spaccisnudeduseSectionX r4, 490-34 490-34.PIPING LEAK ALARM T RIGGERS AUTOMATIC PUMP SHLr=m-%f V•I is checked,dock Ya or No 490.33.FAILUREIDISCONNBCTIONOFTJHE MONITORING SYSTEM TRIGGERSAUTOM=KjMpSHUTD0WN-1fV.I i9 chocked,check Ya orNs c R` 490.36.V-2 PIPE MECHANICAL LIM LEAK DETECTORS PERFORM 3 GPHLEAKTESM jadicaft ifthis moncumg method is used to � � 490.37.MLLD A S)-UW2is s)of9m s)Offbe ' Uncl ak s).M spaceis a x SadonX 490.38.MODEL.#(s)-If V-2 is cbwkK Enterthe model number 1br each type ofmdmkd lite leak detwour'mswk&iramnond spawn needeci,use Section X 490-39.V-3 PIPE ELECTROMC LINE LEAK DETECTORS:Indicate ifthis meettesing method is wed t®motmor the pipelines. 490.40.EI T MANUFACTURER.-MV-3 hicbecked.Entertbounmedths manallummofdoelectrome line teak s). § 490.41.MODEL#(S)n- If V-3 is Chocked,enter the model number for each type ofelocuouic Uno leak detector hwWb&M additional space is weded,usdSecdon X 490-42.PROGRAUMMLDMDTfEGRrrYTEM-WV-3ndwckKcbwkftappmprmftbutodumlmftWMoftmpvwmmucdmotbomomomgsystms � 49043.ELLD DETECTION OF A PIPING LEAKWN-If .11s check Ya orNo 1y 490-44.ELLD DETECTION OFA PIPING LEAK FAILUREIDWONNBCnON TRIGGM PUMP SHUTDOWN.-M V-1 is cbwtK check Ya or No. 49045.V4 PIPE INTEGRITYTESTING e Indicate ifthis monitoung meshod is used to mume,the ' 4W46 TEST FREQUENCY-If V4 is chockK chack the appropriate boat to describe the fisquency of pipe integrity W04r 49047.SPECIFY-M4 is checked,enter ruse of ' 49048.V-S VISUAL PIPE MONITORING- ifthis is to 490-49.If V S is check the boa to describe the finquency of 490-S0.SUCTION PIPING MEETS EMeTION CRZIERIA-Indicate if9da mmmmmg method a used to monnor the pipdmm 490.51.NO REGULATED PIPING PER HEALTH AND SAFErY CODE,DIVISIONA CHAPTER6.7 IS CONNECTED TO THE TANK SYSTEM-amkd&boxffw piping in the task system is regulated underthe UST lar,ortbere isno, ' 490-52.V-99 OTHER-Indicate ifanother method is used for pipeline mwAaft 490.53.SPECIFY-Enters,briefdoscriptionofthe otherlia s M is needed,ser SaKion x Be ems to lady moninxingmeft4s)anciftaquency. This monitoring plan must include a She Plan showing the controlaa) If you a the 1 where is performed(i.a..location of ,line cletactor,monitoring system (ag.. UST Mumtonng Site Pin from a Mnmtormg. System Materials B Plan map,etc.)the alh include it with this f h - 3v7T , UPCF UST D(12/2 214 <` �}