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UNIFIED PROGRAM CONSOLEDATED FORM UNDERGROUND STORAGE TANK MONITORING - e 1 of ) TYPE OF ACTION ❑ 1.NEW PLAN ❑ 2.CHANGE OF INFORMATION 490.1. PLAN TYPE 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): . FACILITY FACILITY ID#(Agency Use Only) 1' BUSINESS NAM as File rN' or D&A 3. BUSINESS SITE ADORE 103 CITY 104. c 1 C A Td& 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.Such work must be performed by qualified personnel.123 CCR§2632 2634.2638.26411 MONITORING EQUIPMENT IS SERVICED I.ANNUALLY [199.OTHER(Specify): 490S if 490-30- -36. II[. MONITORING LOCATIONS ❑ 1.NEW SITE PLOT PLAN/MAP SUBMITTED WITH THIS PLAN K 2.SITE PLOT PLANNAP PREVIOUSLY SUBMITTED [23 CCR§2632,26341 490'4' TANK MONITORINGIS PERFORMED USINGFOLLOWING MEMETHOD(S) 'Chthat act lu) 1.CONTINUOUS ELECTRONIC TANK MONITORING OF ANNULAR(INTERSTITIAL)SPACE(S)OR SECONDARY CONTAINMENT VAULT(S) 49°-5. WITH AUDIBLE AND VISUAL ALARMS.12.3 CCR§263126341 SECONDARY CONTAINMENT IS: DRY ❑ b.LIQUID FILLED ❑ c.PRESSURIZED d.UNDER VACUUM 490.6" PANEL MANUFACTURER: 490-7. MODEL#: ? 490-5. LEAK SENSOR MANUFACTURER: ' 499 MODEL#(S): 2 490-10. ❑ MODEL#: 2.AUTOMATIC TANK GAUGING(ATG)geYSTE USED Tny MONITOR SINGLE WALL TANK(Sl.[23 CCR§26431 PANEL MANUFACTURER: 4vo 11. _` l�+,f,. _.r�..A ✓ �.-�-"� 490-12. 490-13. IN-TANK PROBE MANUFACTURER: 490-14. MODEL#(S): GA 490-15. LEAK TEST FREQUENCY: ❑ a.CONTINUOUS ❑ b.DAILYINIGHTLY ❑ c.WEEKLY 490-16. ❑ d.MONTHLY ❑ e.OTHER(Specify): 490-17. PROGRAMMED TESTS: a.0.1 h. b.0.2 h. ❑ c.OTHERS 1 490-18. ❑ 3.MONTHLY STATISTICAL INVENTORY RECONCILIATION 123 CCR§>_646.1l' 490-20. ❑ 4.WEEKLY MANUAL TANK GAUGING(MTG)123 CCR§26451 TESTING PERIOD: C] 4 a.36 HOURS ❑ b.60 HOURS 490-21, 90.2?. ❑ 5.TANK INTEGRITY TESTING PER[23 CCR§2643.11 490-23. TEST FREQUENCY: ❑ a.ANNUALLY ❑ b.BIENNIALLY [:1c.OTHER(Specify): 490-25. ' 490-26. ❑ 99.OTHER(Specify): 490-27. ! V. T IS (S) that a(Check all 1.CONTINUOUS MONITORING OF PIPE/PIPING SUMP(S)AND OTHER SECONDARY CONTAINMENT WITH AUDIBLE&VISUAL ALARMS. 490-28. I§26368 SECONDARY CONTAINMENT IS: a.DRY ❑ b.LIQUID FILLED ❑ c.PRESSURIZED ❑ d.UNDER VACUUM 490.29. PANEL MANUFACTURER: Ale.( 490.30. MODEL#: y 490.31. LEAK SENSOR MANUFACTURER: ( v i 490-32. MODEL#(S): 490.33. PIPING LEAK ALARM TRIGGERS AUTOMATIC PUMP(i.e., INE)SHUTDOWN. a.YES ❑ b.NO 490'34. FAILURE/DISCONNECTION_OF THE MONITORING SYSTEM TRIGGERS AUTOMATIC PUMP SHUTDOWN. a.YES ❑ b.NO 490-35. IM 2.MECHANICAL LINE LEAK DETECTOR(MLLD)THAT ROUTINELY PERFORMS 3.0 g.p.h.LEAK TESTS AND RESTRICTS OR SHUTS OFF 490-36. PRODUCT FLOW WHEN A LEAK IS DETECTED.[23 CCR§26361 ML°LD MANUFACTURER(S): �T. e 490-37. MODEL#(S): 490-38. ❑ 3.ELECTRONIC LINE LEAK DETECTOR(ELLD)THAT ROUTINELY PERFORMS 3.0 g.p.h.LEAK TESTS.[23 CCR§26361 490-39- ELLD MANUFACTURER(S): 46 MODEL#(S): 440-41. PROGRAMMED IN LINE LEAK TEST: ❑ a.MINIMUM MONTHLY 0.2 g.p.h. ❑ b.MINIMUM ANNUAL 0.1 g.p.K 490-42 ELLD DETECTION OF A PIPING LEAK TRIGGERS AUTOMATIC PUMP SHUTDOWN. ❑ a.YES ❑ b.NO 49013. ELLD FAILURE/DISCONNECTION TRIGGERS AUTOMATIC PUMP SHUTDOWN. ❑ a.YES ❑ b.NO 49044. ❑ 4.PIPE INTEGRITY TESTING. 490.45. TEST FREQUENCY: ❑ a.ANNUALLY b.EVERY 3 YEARS c.OTHERS 1f 4 " Q ❑ ❑ (Specify) ago-Viz_.__ ❑ 5.VISUAL PIPE MONITORING. 490-48. FREQUENCY: ❑ a.DAILY ❑ b.WEEKLY ❑ C.MIN.MONTHLY&EACH TIME SYSTEM OPERATED. 4911-19. *�11oxed fa eeieoring of unburied emugenea-gcaaerazor fiat piping only per HSC§25281.5(bN31 _ _ ❑ 6.SUCTION PIPING MEETS EXEMPTION CRITERIA,123 CCR§2636(aM3)1 ❑ T NO REGULATED PIPING PER HEALTH AND SAFETY CODE,DIVISION 20,CHAPTER 6.7 IS CONNECTED TO THE TANK SYSTEM. 490-51. ❑ 99.OTHER(Specify) 0-90-52 490-53. UPCF UST-D(12/2007)-1/4 www.unidoes.org