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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 OR 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) - I I - 1 BUSINESS NAME(Same as FACILITY NAME) C-/( t�c 1�� `A "��\C-1 L- 3 BUSINESS SITE ADDRESS �'!� 103 1 CITY �33304G 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 EQUIPMENT IS SERVICED I.ANNUALLY ❑ 99.OTHERS cl 490-3-3 MONITORING E Q (Specify): ago-3b III.MONITORING LOCATIONS ❑ 1.NEW SITE PLOT PLAN/MAP SUBMITTED WITH THIS PLAN. ❑2.SITE PLOT PLAN/MAP PREVIOUSLY SUBMITTED. (23 CCR§2632, 2634)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{ PANEL MANUFACTURER: VIS(,, 490-7 MODEL#: _�"(, S 490-8 LEAK SENSOR MANUFACTURER: // k 430-9. MODEL#(S): 7 t"1 -- >I 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): 490-15 -------------------------------------- ------------ ----------- LEAK TEST FREQUENCY: ❑ a.CONTINUOUS ❑ b.DAILY/NIGHTLY ❑ c.WEEKLY 490-11 ❑ 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§2645). TESTING PERIOD: C] a.36 HOURS C319 b.60 HOURS 490-21 0-zz ❑ 5.TANK INTEGRITY TESTING(23 CCR§2643.1): 490-23 TEST FREQUENCY: ❑ a.ANNUALLY ❑ b.BIENNIALLY c.OTHERS If 490-24 Q ❑ (Specify): 490-25 490-26 ❑ 99 OTHER (Specify): 490-27 V.PIPE MONITORING IS PERFORMED USING THE FOLLOWING METHOD(S)(Check all that apply) I.CONTINUOUS MONITORING OF PIPE/PIPING SUMP(S)AND OTHER SECONDARY CONTAINMENT WITH AUDIBLE AND 490.28 VISUAL ALARMS. (23 CCR§2636) SECONDARY CONTAINMENT IS:EAa.DRY ❑b.LIQUID FILLED [1c.PRESSURIZED ❑d.UNDER VACUUM 490.79 PANEL MANUFACTURER: V t?c4.r ti L'JT I 390-30 MODEL#: 0 490-31 LEAK SENSOR MANUFACTURER: tf ► MODEL_#(S):- -- p f� -_ 490-33 PIPING LEAK ALARM TRIGGERS AUTOMATIC PUMP(i.e.,TURBINE)SHUTDOWN ❑a.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 PRODUCT FLOW WHEN A LEAK IS DETECTED(23 CCR§2636) 490-36 MLLD MANUFACTURER(S): ileel _1A k-.,-T 490-37 MODEL#(S): a Fx I V / 8 ❑ 3.ELECTRONIC LINE LEAK DETECTOR(ELLD)THAT ROUTINELY PERFORMS 3.0 g.p.h.LEAK TESTS (23 CCR§2636) 490-39 -- - -- --- -------------- ELLD MANUFACTURER(S) _ _ _ _ -49U40MODEL#(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 49043 ELLD FAILURE/DISCONNECTION TRIGGERS AUTOMATIC PUMP SHUTDOWN. ❑a.YES ❑b.NO 49044 4.PIPE INTEGRITY TESTING 49045 TEST FRE UENCY a.ANNUALLY b.EVERY 3 YEARS c.OTHERS cif 491w6490-47 5.VISUAL PIPE MONITORING. 490-48 FREQUENCY ❑ a.DAILY ❑ b.WEEKLY ❑C.MIN.MONTHLY&EACH TIME SYSTEM OPERATED- 49049 •Allowed for monitoring of unburied emffgmcy genwatm fuel piping only pa HSC 25281.5(b)13) ❑ 6.SUCTION PIPING MEETS EXEMPTION CRITERIA 123 CCR§2636(a)(3)1. 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) 490.53 UPCF UST-D(12/2007)1/4