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• 11 • UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK MONITORING PLAN - (Page 1 of 2) TYPE OF ACTION ❑ 1. NEW PLAN 2. CHANGE OF INFORMATION 490-1. PLAN TYPE In 1. MONITORING IS ID TICAL FOR ALL USTs AT THIS FACILITY. ago -z (Check one item only) ❑ 2. THIS PLAN COVERS ONLY THE FOLLOWING UST SYSTEM(S): I. FACILITY INFORMATION FACILITY ID # (Agency Use Only) 1. BUSINESS NAME (Same as Facility Name or DBA) 3. BUSINESS SITE ADDRESS 103. ? W• 9 4bl CITY 104- II. EQUIPMENT TESTING AND PREVENTIVE 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 annuall , whichever is more frequent. Such work must be performed by qualified personnel. [23 CCR §2632, 2634, 2638, 26411 a90 -3a MONITORING EQUIPMENT IS SERVICED L ANNUALLY ❑ 99. OTHER (Specify): 490-36. III. MONITORING LOCATIONS ❑ 1. NEW SITE PLOT PLAN/MAP SUBMITTED WITH THIS PLAN 2. SITE PLOT PLAN/MAP PREVIOUSLY SUBMITTED [23 CCR §2632,26341 490-4. . TANK MONITORING IS PERFORMED USING THE FOLLOWING METHOD(S) (Check all IVthatapply) 1. CONTINUOUS ELECTRONIC TANK MONITORING OF ANNULAR (INTERSTITIAL) SPACE(S) OR SECONDARY CONTAINMENT VAULT(S) 490-5. WITH AUDIBLE AND VISUAL ALARMS. 123 CCR §2632,26341 SECONDARY CONTAINMENT IS: ❑ a. DRY V b. LIQUID FILLED ❑ c. PRESSURIZED ❑ d. UNDER VACUUM 490-6. PANEL MANUFACTURER: V F_>F_ p F_IL P-00 -T 490-7. MODEL #: 1 L S 3 5_0 490-8. LEAK SENSOR MANUFACTURER: V F 6 D P-0-0 -.r 490-9. MODEL #(S): % q �'3 B Q - Z O 490-10. [12. AUTOMATIC TANK GAUGING (ATG) SYSTEM USED TO MONITOR SINGLE WALL TANK(S). [23 CCR §26431 49x11. PANEL MANUFACTURER: 490-12' MODEL #: 490-13' IN -TANK PROBE MANUFACTURER: 490-14. MODEL #(S): 490-15. LEAK TEST FREQUENCY: ❑ a. CONTINUOUS ❑ b. DAILY/NIGHTLY ❑ c. WEEKLY 490-16. ❑ d. MONTHLY ❑ e. OTHER (Specify): 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 §26451 TESTING PERIOD: C] a. 36 HOURS ❑ b. 60 HOURS 490-22. 21. ❑ 5. TANK INTEGRITY TESTING PER 123 CCR §2643.11 490-23. c. OTHER (Specify): 49255.24. TEST FREQUENCY: a. ANNUALLY ❑ b. BIENNIALLY El4 _❑ ❑ 99. OTHER (Specify): 490.2726. V. PIPE MONITORING IS PERFORMED USING THE FOLLOWING METHOD(S) "heck au 1. CONTINUOUS MONITORING OF PIPE/PIPING SUMP(S) AND OTHER SECONDARY CONTAINMENT WITH AUDIBLE & VISUAL ALARMS. 490-28. [23 CCR SECONDARY CONTAINMENT IS: C34. DRY ❑ b. LIQUID FILLED ❑ c. PRESSURIZED ❑ d. UNDER VACUUM 490.29. §2636] PANEL MANUFACTURER: V £ E D IZ R- d O j 490-30. MODEL #: I (► -S " 3 �0 490-31. LEAK SENSOR MANUFACTURER: 'V F_ E D ±]L f2-007- 490-32. MODEL #(S): % q _7 p Ef 490-33. PIPING LEAK ALARM TRIGGERS AUTOMATIC PUMP (i.e., TURBINE) SHUTDOWN. toa. YES ❑ b. NO 490-34' FAILURE/DISCONNECTION 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 490-36, PRODUCT FLOW WHEN A LEAK IS DETECTED. [23 CCR§26361 MLLD MANUFACTURER(S): SE F_ 2,F l.0 � 490 37' MODEL #(S): s t � f l..6 k.,;490-38. ❑ 3. ELECTRONIC LINE LEAK DETECTOR (ELLD) THAT ROUTINELY PERFORMS 3.0 g.p.h. LEAK TESTS. [23 CCR§26361 490-39. ELLD MANUFACTURER(S): 490_40' MODEL #(S): 49041. PROGRAMMED IN LINE LEAK TEST: Fla. MINIMUM MONTHLY 0.2 g.p.h. ❑ b. 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 FAILURE/DISCONNECTION TRIGGERS AUTOMATIC PUMP SHUTDOWN. ❑ a. YES ❑ b. NO 490' ❑ 4. PIPE INTEGRITY TESTING. 490-45, 490-06. TEST FREQUENCY: a. ANNUALLY ❑ b. EVERY 3 YEARS ❑ c. OTHER (Specify) 490-47. _ _❑ ❑ 5. VISUAL PIPE MONITORING. 490.48. FREQUENCY: ❑ a. DAILY ❑ b. WEEKLY ❑ C. MIN. MONTHLY & EACH TIME SYSTEM OPERATED* 49x49. Allowed for mmitoring of unburied emergency generator fuel piping only r HSC 25281.5(6)(3 ❑ 6. SUCTION PIPING MEETS EXEMPTION CRITERIA. 123 CCR §2636(ax3)] 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) 49as3.52. UPCF UST -D (12/2007) -1/4 f3 •7 V A f C fL L ESS www.uuidocs.org C oj I %/AR0rL LF -SS (VM f 1 Di FS EL • ✓ E D iL®QT i/MT) i-- 17. 2voo LD20D6 PXIDV