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low UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK MONITORING PLAN-(Pae 1 of 2) 490.1 TYPE OF ACTION ❑ 1.NEW PLAN 2.CHANGE OF INFORMATION 490-2 PLAN TYPE 1.MONITORING IS IDENTICAL FOR ALL USTs AT THIS FACILITY. i (Check one item only) ❑ 2.THIS PLAN COVERS ONLY THE FOLLOWING UST SYSTEM(S-c I. FACILITY INFORMATION 1 FACILITY ID#(Agency Use Orly) 3. BUSINESS NAME(Same as FACILITY NAME) 103. CITY 104. i BUSINESS SITE ADDRESS Y II.EQUIP 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) 490.3& MONITORING EQUIPMENT IS SERVICED 1.ANNUALLY ❑ 99.OTHER(Specify): 490-36 M.MONITORING LOCATIONS 1.NEW SITE PLOT PLAN/MAP SUBMITTED WITH THIS PLAN. [12.SITE PLOT PLAN/MAP PREVIOUSLY SUBMITTED. (23 CCR§2632, 2634)490-4 IV.TANK MONITORING IS PERFORMED USING THE FOLLOWING METHOD(S): 490-5 1.CONTINUOUS ELECTRONIC TANK MONITORING OF ANNULAR(INTERSTITL4L)SPACE(S)OR SECONDARY CONTAINMENT VAULT(S)WITH AUDIBLE AND VISUAL ALARMS. (23 CCR§2632,2634) 490.6 SECONDARY CONTAINMENT IS: a.DRY ❑ b.LIQUID FILLED ❑ c.PRESSURIZED ❑d.UNDER VACUUM 490.7. ' MODEL#: /EZ- C?(_i 490-9 PANEL MANUFACTURER: 490-10 � - -390.9 MODEL#(S): XLS LEAK SENSOR MANUFACTURER: 490 11 2.AUTOMATIC TANK GAUGING(ATG)SYSTEM USED TO MONITOR SINGLE WALL�TANK(@.(23 CCR§2643) 49x13 PANEL MANUFACTURER: 11. MODEL#: 490-14. MODEL#(S): 490-15 IN-TANK PROBE MANUFACTURER: 490-16 LEAK TEST FREQUENCY: ❑ a.CONTINUOUS ❑ b.DAILY/NIGHTLY ❑ c.WEEKLY 490.17 ❑ d.MONTHLY ❑ e.OTHER(Specify): _ 490.18 PROGRAMMED TESTS: ❑ a.0.1 g.p.h. ❑ b.0.2 g.p.h. ❑ c.OTHER(Specify): 490.19 490-20 ❑ 3.MONTHLY STATISTICAL INVENTORY RECONCILIATION(23 CCR§2646.1): 490-21 ❑ 4.WEEKLY MANUAL TANK GAUGING(TG)(23 CCR§264-5). TESTING PERIOD: ❑ a.36 H_OLTRS ❑ h.60 I401IRS 490.22 490-23 5.TANK INTEGRITY TESTING(23 CCR§2643.1): 490.24 +'i'�l TEST FREQUENCY: a.ANNUALLY ❑ b.BIENNIALLY ❑ c.OTHER(Specify): 490-25 490.26 ❑99.OTHER (Specify): 490.27 . IPE MONITORING IS PERFORMED USING THE FOLLOWING METHOD(S)(Check all t a 1.CONTINUOUS MONITORING OF PIPE/PIPING SUMPS)AND OTHER SECONDARY CONTAINMENT WITH AUDIBLE AND VISUAL ALARMS. (23 CCR§2636) 490-29 SECONDARY CONTAINMENT IS:❑a.DRY ❑b.LIQUID FILLED 0c.PRESSURIZED ❑d.UNDER VACUUM 49x3 490-30 MODEL#: PANEL MANUFACTURER: 490 3z 4 3 LEAK SENSOR MANUFACTURER: ; MODEL a.YES ❑b.NO 30- PIPING LEAK ALARM TRIGGERS AUTOMATIC PUMP(i.e.,TURBINE)SHUTDOWN. ❑ 490 35 AILURE/DISCONNECTION AUTOMATIC PUMP SHUTDOWN. ❑a-YES ❑b.NO 2.MECHANICAL LINE LEAK DETECTOR(MLLD)THAT ROUTINELY PERFORMS 39-Pt)1 OFF PRODUCT FLOW WHEN A LEAK IS DETECTED 23 CCR 2636 j 490.36 490.37 MODEL#(S): Y 490- 38 MLLD MANUFACTURER(S): 490-39 ❑ 3.ELECTRONIC LINE LEAK DETECTOR(ELLD)THAT ROUTINELY PERFORMS 3.0 g.p.h.LEAK TESTS (23 CCR§263 490-41 49010. , MODEL#(S): ELLD MANUFACTURER(S) _ 49042 PROGRAMMED IN LINE LEAK TEST: ❑ 1.MINIMUM MONTHLY 0.2 g.p.h. ❑ 2.MINIMUM ANNUAL 0.1 g.p.h. ❑a.YES ❑b.NO 49043 ELLD DETECTION OF A PIPING LEAK TRIGGERS AUTOMATIC PUMP SHUTDOWN. 490.44 ELLD FAILURE/DISCONNECTION TRIGGERS AUTOMATIC PUMP SHUTDOWN. ❑a.YES ❑b.NO 4.PIPE INTEGRITY TESTING 490.45 490-46490.47 TEST UENCY a.ANNUALLY b.EVERY 3 YEARS ❑ c.OTHER S ecifv 490.48 5.VISUAL PIPE MO T RING. FREQUENCY ❑ a.DAILY [-] b.WEEKLY Ipt c.MIN.MONTHLY&EACH TIME SYSTEM OPERATED- x90 0-9 Allowed for monitonag of m tried&mer cv ralor fuel n onl` er HSC 5281.5 490-50 ❑ 6.SUCTION PIPING MEETS EXEMPTION CRITERIA 123 CCR§2636(.)(3)1. 7.NO REGULATED PIPING PER HEALTH AND SAFETY CODE,DIVISION 20,CHAPTER-6.7IS CONNECTED TO THE TANK SYSTEM 490-51 490.52 490-53 ❑ 99.OTHER(Specify) UPCF UST-D(12/2007)1/4