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TIED PROGRAM CONSOLIDATED FORM �./ UNDERGROUND STORAGE TANK MONITORING PLAN-(Page I of 2) TYPE OF ACTION ❑ 1.NEW PLAN ® 2.CHANGE OF INFORMATION 490 1 PLAN TYPE ® I.MONITORING IS IDENTICAL FOR ALL USTs AT THIS FACILITY 490.3 (Check one item only) ❑ 2.THIS PLAN COVERS ONLY THE FOLLOWING UST SYSTEM(S)' I. FACILITY INFORMATION FACILITY ID k(Agency Use Only) - - 1 BUSINESS NAME(Same as FACILITY NAME) Circle K Store #2701205 3 BUSINESS SITE ADDRESS 16470 Cambridge Streetl0i CI"TY Lathrop 10a II. EQUIPMENT TESTING AND PREVENTIVE MAINTENANCE Testing,preventive maintenance,and calibration of monitoring equipment(eg.,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 -.__.____. _ ______________________-_AAAA______-____.__. § � a9o-3. MONITORING EQUIPMENT IS SERVICED ® 1. ANNUALLY ❑ 99.OTHER(Specify): 49o-36 III. MONITORING LOCATIONS S 1.NEW SITE PLOT PLAN/MAP SUBMITTED WITH THIS PLAN. ❑2.SITE PLOT PLAN/31AP PREVIOUSLY SUBMITTED. (23 CCR 12632, 2634)49 IV.TANK MONITORING IS PERFORMED USING THE FOLLOWING'METHOD(S): ® L 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 S b.LIQUID FILLED ❑ c.PRESSURIZED ❑d.UNDER VACUUM 49-6 PANEL MANUFACTURER: Veeder Root 411_ �MODEL 9: TLS-350 410-' LEAK SENSOR MANUFACTURER: Veeder Root 490-9. I MODEL il(S): 794380-303 440-10 2.AUTOMATIC TANK GAUGING(ATC)SYSTEM USED TO MONITOR SINGLE WALL TANK(S).(23 CCR§2643) 490-1) PANEL MANUFACTURER: 480-1= MODEL N: 490-D __----------------- -______________________ IN-TANK PROBE MANUFACTURER: .,90,14 MODEL ft(S): 49-19 --._...__.____-____.____..._.._._...._____...._._....-_.___ LEAK TEST FREQUENCY: ❑ a.CONTINUOUS ❑ b. DAILYNIGHTLY ❑ c.WEEKLY 49-16 ❑ d.MONTHLY ❑ e.OTHER(Specify): 490'12 PROGRAMMED TESTS: ❑ a.0.1 g.p.h. ❑ b.0.2 g.p.h. ❑ c.OTHER(Specify): anis ❑ 3.MONTHLY STATISTICAL INVENTORY RECONCILIATION(23 CCR§2646.1): 490-20 ❑ 4.WEEKLY MANUAL TANK GAUGING(NITC)(23 CCR§2645). TESTING PERIOD: ❑ a.36 HOURS ❑ b.60 HOURS n 0-22 i 5.TANK INTEGRITY TESTING(23 CCR§2643.1): 49-23 TEST FREQUENCY: ❑ a. ANNUALLY ❑ b. BIENNIALLY ❑ c.OTHER(Specify): ew 35 ❑99.OTHER (Specify): a9Wo-26 27 V. PIPE MONITORING IS PERFORMED USING THE FOLLOWING METHOD(S)(Check all that apply) I.CONI"INUOUS MONITORING OF PIPE/PIPING SUMP(S).AND OTHER SECONDARY CONTAINMENT WITH AUDIBLE AND 490-28 VISUAL ALARMS. (23 CCR§2636) SECONDARY CONTAINMENT IS: Sa.DRY ❑b.LIQUID FILLED ❑c.PRESSURIZED ❑d. UNDER VACUUM 490'29 __._..._ _._-______-. W030 I 490-31 r PANEL MANUFACTURER: Veeder Root __-_---------------------___ _MODEL pTLS_350 LEAK SENSOR MANUFACTURER: Veeder Root °90-12 MODEL i#(S): 794380-208 490-'3 __._.._..____.________--_________ � ________________-__._______-________®_____.___..__________-__. PIPING LEAK ALARM TRIGGERS AUTOMATIC PUMP(i.e.,TURBINE SHUTDOWN. a. YES ❑b.NO 4W-34 FAILUREIDISCONNECTION OF THE MONITORING SYSTEM TRIGGERS AUTOMATIC PUMP SHUTDOWN. S a.YES ❑b.NO 490-35 r 2. MECHANICAL LINE LEAK DETECTOR(VILLD)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 _______S.____- ___�_____________________.__.______ MLLD MANUFACTURER(S): Red Jacket / FE Petro 490-31 MODEL#(S): FX I V / MLD 490-33 ❑ 3. ELECTRONIC LINE LEAK DETECTOR(ELLD)THAT ROUTINELY PERFORMS 3.0 g.p.h.LEAK TESTS (23 CCR§2636) 49-349 _._490-41 ELLD MANUFACfUR_ER(S) __ _ _ _ _ MODEL k(S): . 4 PROGRAMMED IN LINE LEAK TEST. ❑ 1.MINIMUM MONTHLY 0.2 g.p.h. ❑ 2.MINIMUM ANNUAL 0 g.p.h 490.42 ELLD DETECTION OF A PIPING LEAK TRIGGERS AUTOMATIC PUMP SHUTDOWN. ❑a. YES ❑b NO 44041 ELLD FAILURE/DISCONNECTION TRIGGERS AUTOMATIC PUMP SHUTDOWN. ❑ a. YES ❑b. NO 49044 ❑ 4.PIPE INTEGRITY TESTING 49045 TEST FREQUENCY ❑ a.ANNUALLY ❑ b. EVERY 3 YEARS ❑ c.OTHER(Specify) 49-46490-4r ❑ 5.VISUAL PIPE MONITORING. 4904x1 FREQUENCY ❑ a.DAILY ❑ b.WEEKLY ❑c MIN MONTHLY&EACH TIME SYSTEM OPERATED' awl-wj ,Allowfar moniwrtng of wi wto emer eeraur fueli only6 r HSC 15281 5 l ❑ 6.StCTION PIPING MEETS EXEMPTION CRITERIA 123 CCR§2636(a)(3)1. 490-s0 ❑ 7 NO REGCLA rED PIPING PER HEAL VH \NI)SAFE"FY CODE,DIVISION 21).CHAP-ER 6.7 IS CONNECTED TO THF:TANK SYSTEM J9-51 ❑ 99.OTHER(Specify) 4*ro-s3 ta'CF t'ST-D(12/2007)