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U`*N,.KIED PROGRAM CONSOLIDATED FORM .ws UNDERGROUND STORAGE TANK MONITORING PLAN-(Page I of 2) TYPE OF ACTION ❑ L NEW PLAN ® 2.CHANGE OF INFORMATION 490.1 PLAN TYPE ® 1.MONITORING IS IDENTICAL FOR ALL USTs AT THIS FACILITY. 4W2 (Check one item only) ❑ 2.THIS PLAN COVERS ONLY THE FOLLOWING UST SYSTEM(S) I. FACILITY INFORMATION FACILITY ID#(Agency Un Only) BUSINESS NAME(Some as FACILITY NAME) Circle K Store #2701205 x BUSINESS SITE ADDRESS 16470 Cambridge.Street 101' CITY Lathrop 1°9 n.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 mast be performed by qualified personnel. 3 CCR§2632,2634 2638,2641Z_-------_________ _________ _ _ _-__.. MONITORING EQUIPMENT IS SERVICED ® L ANNUALLY ❑ 99,OTHER(Specify): 490-36 490-x9 M.MONITORING LOCATIONS E L NEW SITE PLOT PLAN/MAP SUBMITTED WITH THUS PLAN. ❑2.SITE PLOT PLANIMAP PREVIOUSLY SUBMITTED. (23 CCR§2632, 2634)490-4 IV.TANK MONITORING IS PERFORMED USING THE FOLLOWING METHOD(S): JR 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: ❑ e.DRY E b.LIQUID FILLED ❑ c.PRESSURIZED ❑d.UNDER VACUUM 490-6 PANEL MANUFACTURER: Veeder Root _ 090.1 MODEL#: TLS-350 4902 LEAK SENSOR MANUFACTURER: Veeder Root 9909 MODEL#(S): 794380-303 °90-10 ❑ 2.AUTOMATIC TANK GAUGING(ATG)SYSTEM USED TO MONITOR SINGLE WALL TANK(S).(23 CCR§2643) 490.11 PANEL MANUFACTURER: 490-12. MODEL#: -_ _ -_ 4W IN-TANK PROBE MANUFACTURER: 49014. _MODEL#(S): _ a9a-1s LEAK TEST FREQUENCY:` ❑ 0.CONTINUOUS ❑ b.DAILY/NIGHTLY ❑ c.WEEKLY +9616 ❑ d.MONTHLY ❑ e.OTHER(Specify): _ _ -__ 490.11 PROGRAMMED TESTS: ❑ e.0.3 g.p.h. ❑ h.0.2 g.p.h. ❑ c.OTHER(Specify): 4W19- 49619 ❑ 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 ❑ b.60 HOURS 4WD 490-x2 El 5.TANK INTEGRITY TESTING(23 CCR§2643.1): 490.24 TESTPREQUENCY: [Ia.ANNUALLY E] b.BIENNIALLY Elc.c.OTHER(Specify): 4xs 190.24 ❑99.OTHER (Specify): 490.27 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 CONTAINMENTWITH AUDIBLE AND 0_02s VISUAL ALARMS. (23 CCR§2636) SECONDARY CONTAINMENT IS:Ea.DRY [3b.LIQUID FILLED ❑c.PRESSURIZED ❑d.UNDER VACUUM ,90..x9 i'9o:io490.31 PANEL MANUFACTURER: Veeder Root MODEL#: TLS-350 LEAK SENSOR MANUFACTURER: Veeder Root _ 490.32 MODEL#(s)_ 794380-208990'x3 PIPING LEAK ALARM TRIGGERS AUTOMATIC PUMP(i.e.,TURBINE)SHUTDOWN. ®e.YES ❑It.NO 490'34 FAILURE/DISCONNECTION OF THE MONITORING SYSTEM TRIGGERS AUTOMATIC PUMP SHUTDOWN. E e.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 DETECTE_D123 CCR2¢ 636) IW36 MLLD MANUFACfURERM:Regular-FE Petro/Premium-Red Jacket ;900. MODEL#(S):Reg.#MLD/Prem.#FXtV 490.32 ❑ 3.ELECTRONIC LINE LEAK DETECTOR(ELLD)THAT ROUTINELY PERFORMS 3.0 g.p.h.LEAK TESTS (23 CCR§2636) 49x39 ELLD MANUFACTURER(S) PROGRAMMED IN LINE LEAK TEST: ❑ 1.MINIMUM MONTHLY 0.2 g.p.h. ❑ 2.MINIMUM ANNUAL 0.1 gF.h. 990'4' ELLD DETECTION OF A PIPING LEAK TRIGGERS AUTOMATIC PUMP SHUTDOWN. ❑ a.YES ❑It.NO 49w3 ELLD FAILURE/DISCONNECTION TRIGGERS AUTOMATIC PUMP SHUTDOWN. ❑ a.YES ❑b.NO 49044 4.PIPE INTEGRITY TESTING 49642 TEST FRE UENCY ❑ &ANNUALLY ❑ b.EVERY 3 YEARS ❑ c.OTHER(Specify) 4w-4649nA? 5,VISUAL PIPE MONITORING. w0.49 FREQUENCY ❑ a.DAILY ❑ b.WEEKLY ❑C.MIN.MONTHLY&EACH TIME SYSTEM OPERATED' 49049 •Allowed Nr nwnimri 0f9n6uriM arae airc iwrnor fuel i in oni r HSC x528 L5 6 ❑ 6.SUCTION PIPING MEti 1'S EXEMPTION CRITERIA 123 CCR§2636(a)(3)1. 49o-50 El 7.NO REGULATED PIPING PER HEALTH AND SAFETY CODE,DIVISION 20,CHAPTER 6.1 IS CONNECTED TO THE TANI(SYSTEM 490-St 49D-Sx ❑ 99.OTHER(Specify) 490-sx