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UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK MONITORING PLAN-(Page I of 2) TYPE OF ACTION ❑ I.NEW PLAN ® 2.CHANGE OF INFORMATION 494-1 PLAN TYPE ® 1.MONITORING IS IDENTICAL FOR ALL LISTS AT THIS FACILITY. 4902 (Check one item only) ❑ 2.THIS PLAN COVERS ONLY THE FOLLOWING UST SYSTEM S), I. FACHATY INFORMATION FACILITY ID#(Agency Use Only) BUSINESS NAME(Same as FACILITY NAME) Circle K Store #2701205 ' BUSINESS SITE ADDRESS 16470 Cambridge Street 103 1 CITY Lathrop la. H.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 ® I.ANNUALLY ❑ 99,OTHER(Specify): 4961 490.16 M.MONITORING LOCATIONS ®1.NEW SITE PLOT PLAN/MAP SUBMITTED WITH THIS PLAN. 112.SITE PLOT PLAN/MAP PREVIOUSLY SUBMITTED. (23 CCR§2632, 2634)4 IV.TANK MONITORING IS PERFORMED USING THE FOLLOWING METHOD(S): I.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 0506 PANEL MANUFACTURER: Veeder Root 490.2 MODEL#: TLS-350 4968 LEAK SENSOR MANUFACTURER: Veeder Root 990-9 MODEL#(S): 794380-303 490-10 ❑ 2.AUTOMATIC TANK GAUGING(ATG)SYSTEM USED TO MONITOR SINGLE WALLTANK(S).(23 CCR§2643) 490.1 I PANEL MANUFACTURER: 490.12. MODEL#: g00.1' __ -_ .-__--_____ _.__-________- IN-TANK PROBE MANUFACTURER: 49-14. MODEL HIS): 490-15 LEAK TEST FREQUENCY: ❑ a.CONTINUOUS ❑ b.DAILY/NIGHTLY ❑ c.WEEKLY 490-16 ❑ d.MONTHLY ❑ e.OTHER(Specify): 490-17 PROGRAMMED TESTS: ❑ a.0.1 h. ❑ b.02 h. ❑ c.OTHER(Specify): 490-18 g�P� g�P� ( P fY)� 990-19 ❑ 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 C1 b.60 HOURS 490.21 _ 4M 22 _CF5 .TANK INTEGRITY TESTING(23 CCR§2643.1): 490-23 TEST FREQUENCY: ❑ a.ANNUALLY El b.BIENNIALLY El c.OTHER490-24 Q (Specify): 49x25 ❑ 99.OTHER (Specify): --- 49-26 490-22 V.PIPE MONITORING IS PERFORMED USING THE FOLLOWING METHOD(S)(Check all that apply) I.CONTINUOUS MONITORING OF PIPE!PIPING SUNIP(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 49-29 PANEL MANUFACTURER: Veeder Root 49110 I MODEL#: TLS-350 40.31 LEAK SENSOR MANUFACTURER: Veeder Root 412 MODEL#(5)__794380-208 490-11 PIPING LEAK ALARM TRIGGERS AUTOMATIC PUMP(i.e.,TURBINE)SHUTDOWN. ®a.YES ❑b.NO 490-34 FAILUREIDISCONNECTION OF THE MONITORING SYSTEM TRIGGERS AUTOMATIC PUMP SHUTDOWN. S&YES ❑b.NO 49-35 2.MECHANICAL LINE LEAK DETECTOR(MLLD)THAT ROUTINELY PERFORMS 3.0 g.p.h.LEAK TESTS AND RESTRICTS ORSHUTS OFF PRODUCT FLOW WHEN A LEAK IS DETECTED(23 CCR§2G36) _ 49636 MLLD MANUFACTURER(S):Regular-FE Petro/Premium-Red Jacket jj6 MODEL#(S):Reg.HMLD/Prem.#FXI V 496'8 ❑ 3.ELECTRONIC LINE LEAK DETECTOR(ELLD)THAT ROUTINELY PERFORMS 3.0 g.p.h.LEAK TESTS (23 CCR§2636) 49-39 ELLD MANUFACTURER40.S) 49- MODEL#(S): 49-41 PROGRAMMED IN LINE LEAK TEST: ❑ 1.MINIMUM MONTHLY 0.2 gp.h. ❑ 2.MINIMUM ANNUAL 0.1 g.p.h. 0904 ELLD DETECTION OF A PIPING LEAK TRIGGERS AUTOMATIC PUMP SHUTDOWN. ❑a.YES ❑b.NO 49()-43 ELLD FAILUREIDISCONNECTION TRIGGERS AUTOMATIC PUMP SHUTDOWN. ❑a.YES ❑b.NO 490-44 4.PIPE INTEGRITY TESTING 490.15 TEST FREQUENCY ❑ a.ANNUALLY ❑ b.EVERY 3 YEARS ❑ c.OTHER(Specify) 49-46490A2 Ll 5.VISUAL PIPE MONITORING. 49-48 FREQUENCY ❑ a.DAILY ❑ b.WEEKLY ❑C.MM.MONTHLY&EACH TIME SYSTEM OPERATED- 49649 •Aft x form hwi orun AM eme lm amt piping oIy W HSC 25261.5 ❑ 6.SUCTION PIPING MEETS EXEMPTION CRITERIA 123 CCR§2636(a)(3)1. 49650 7.NO REGULATED PIPING PER HEALTH AND SAFETY CODE,DIVISION 20,CHAPTER 6.7 IS CONNECTED TO THE TANK SYSTEM 49-51 ❑ 99.OTHER(Specify) 49-52 490-53