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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(S)-- I. FACILITY INFORMATION FACILITY ID#(Agency Use Only) BUSINESS NAME(Same as FACILITY NAME) 3. BUSINESS SITE ADDRESS 103, 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 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.OTHERS eci fq� 490-3a ( P •7)� 490-3b III.MONITORING LOCATIONS 1.NEW SITE PLOT PLAN/MAP SUBMITTED WITH THIS PLAN. ❑2.SITE PLOT PLAN/MAP PREVIOUSLY SUBMITTED. (23 CCR§2632, 104)490-4 490-4 IV.TANK MONITORING IS PERFORMED USING THE FOLLOWING METHOD(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: _ _ _ _ 490.7 MODEL#: _ 490.8 LEAK SENSOR MANUFACTURER: 490-9. MODEL#(S): 490-10 2.AUTOMATIC TANK GAUGING(ATG)SYSTEM USED TO MONITOR SINGLE WALL TANK(S).(23 CCR§2643) 490-11 PANEL MANUFACTURER: 490-12. MODEL#: 490-13 IN-TANK PROBE MANUFACTURER: 490-14. MODEL#(S): 490-I5 LEAK TEST FREQUENCY: .CONTINUOUS ❑ b.DAILY/NIGHTLY ❑ c.WEEKLY 490-16 _❑ d.MONTHLY ❑ e.OTHER(Specify): 490-17 PROGRAMMED TESTS: ❑ a.0.1g Ph. 490-18❑ b.0.2 g.Ph. c.OTHER(S ecify): 490-19 3.MONTHLY STATISTICAL INVENTORY RECONCILIATION(23 CCR§2646.1): 490-20 `{Z[ 4.WEEKLY MANUAL TANK GAUGING(MTG)(23 CCR§2645). TESTING PERIOD: E] a.36 HOURS El b.60 HOURS a 0-22 5.TANK INTEGRITY TESTING(23 CCR§2643.1): 490-23 TEST FREQUENCY: a.ANNUALLY ❑ b.BIENNIALLY ❑ c.OTHERS eci 490-24 Q (Specify): 490-25 ❑99.OTHER (Specify): 490-26 ago-z7 V.PIPE MONITORING IS PERFORMED USING THE FOLLOWING METHOD(S)(Check all that apply) 1.CONTINUOUS MONITORING OF PIPE/PIPING SUMP(S)AND OTHER SECONDARY CONTAINMENT WITH AUDIBLE AND 490-28 ISUAL ALARMS. (23 CCR§2636) SECONDARY CONTAINMENT IS:❑a.DRY ❑b.LIQUID FILLED [1c.PRESSURIZED ❑d.UNDER VACUUM 490-29 _PANEL MANUFACTURER: _ 49130 MODEL#: 490-31 LEAK SENSOR MANUFACTURER 490-32 MODEL#(S): 490-33 PIPING LEAK ALARM TRIGGERS AUTOMATIC PUMP(i.e.,TURBINE)SHUTDOWN. ❑a.YES ❑b.NO 490-34 FAILUREMISCONNECTION 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 2636 490-36 MLLD MANUFACTURER(S): 490-37 MODEL#(S): 490-38 3.ELECTRONIC LINE LEAK DETECTOR(ELLD)THAT ROUTINELY PERFORMS 3.0 g.p.h.LEAK TESTS (23 CCR§2636) 490-39 ELLD MANUFACTURER(S) 490-d0' MODEL#(S): 49041 PROGRAMMED IN LINE LEAK TEST: ❑ 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 FAILURE/DISCONNECTION TRIGGERS AUTOMATIC PUMP SHUTDOWN. ❑a.YES ❑b.NO 49044 QL 4.PIPE INTEGRITY TESTING 490-45 TEST FREQUENCY a.ANNUALLY ❑ b.EVERY 3 YEARS ❑ c.OTHER(Specify) 490-46 490-47 5.VISUAL PIPE MONITORING. 49048 FREQUENCY ❑ a.DAILY ❑ b.WEEKLY ] C.MIN.MONTHLY&EACH TIME SYSTEM OPERATED* 490-49 *Allowed for monitoring of unburied emergency enerator fuel piping only per HSC§25281.5(b)(3 6.SUCTION PIPING MEETS EXEMPTION CRITERIA[23 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 1 ❑ 99.OTHER(Specify) 490-52 490-53 UPCF UST-D(12/2007)1/4