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1 J e 0 UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK MONITORING PLAN -(Page 2 of 2) VI.UNDER DISPENSER CONTAINMENT(UDC)MONITORING (Check U that a 1l UDC MONITORING IS PERFORMED USING THE FOLLOWING METHOD(S) 1.CONTINUOUS ELECTRONIC MONITORING ❑ 2.FLOAT AND CHAIN ASSEMBLY ❑ 3.ELECTRONIC STAND-ALONE 490-54a. ❑_-4.-.NO DISPENSERS 99-OT _R(_S_�eci Y) r3 49.-0-54b_. 49o•s�. 490_-6 LEAK MONITOR MANUFACTURER: MODEL#: ._ LEAK SENSOR MANUFACTURER: r"/ 490-57. MODEL#(S): L S - j 490-58' DETECTION OF A LEAK INTO THE UDC TRIGGERS AUDIBLE AND VISUAL ALARMS. a.YES ❑ b.NO 490159. UDC LEAK ALARM TRIGGERS AUTOMATIC PUMP SHUTDOWN. a.YES ❑ b.NO 490-60. FAILURE/DISCONNECTION OF UDC MONITORING SYSTEM TRIGGERS AUTOMATIC PUMP SHUTDOWN. C9 a.YES ❑ b.NO 490-61. UDC MONITORING STOPS THE FLOW OF PRODUCT AT THE DISPENSER. a.YES ❑ b.NO 490-62. UDC CONSTRUCTION IS: l.SINGLE WALL 2.DOUBLE WALL 490-63. IF DOUBLE WALL: 490-640- UDC INTERSTITIAL SPACE IS MONITORED BY: ❑ a.LIQUID ❑ b.PRESSURE ❑ c.VACUUM A LEAK WITHIN THE SECONDARY CONTAINMENT OF THE UDC TRIGGERS AUDIBLE AND VISUAL ALARMS. ❑ a.YES ❑ b.NO 490-64b. VII. PERIODIC SYSTEM TESTING ❑ 1.ELD TESTING: THIS FACILITY HAS BEEN NOTIFIED BY THE STATE WATER RESOURCES CONTROL BOARD THAT ENHANCED 490-65. LEAK DETECTION(ELD)MUST BE PERFORMED. PERIODIC ELD IS PERFORMED EVERY 36 MONTHS AS REQUIRED.[23 CCR§2644.11 ® 2.SECONDARY CONTAINMENT COMPONENTS ARE TESTED EVERY 36 MONTHS. 490-66. ® 3.SPILL BUCKETS ARE TESTED ANNUALLY. 490-67. VIII.- RECORD KEEPING The following monitoring/maintenance records are kept for this facility: 490-68. ® a.ALARM LOGS ❑ b.VISUAL INSPECTION RECORDS ❑ c.TANK INTEGRITY TESTING RESULTS ❑ d.SIR TESTING RESULTS(and supporting documentation records) ❑ e.TANK GAUGING RESULTS(and supporting documentation records) ❑ f ATG TESTING RESULTS(and supporting documentation records) ❑ g.CORROSION PROTECTION 60-DAY LOGS ® h.EQUIPMENT MAINTENANCE AND CALIBRATION RECORDS IX. TRAINING ® Personnel with UST monitoring responsibilities are familiar with all of the following documents relevant to their job duties: 4%-69a. REFERENCE DOCUMENTS MAINTAINED AT FACILITY(Check all that apply) ® THIS UNDERGROUND STORAGE TANK MONITORING PLAN(Required) 490-69b. ® OPERATING MANUALS FOR ELECTRONIC MONITORING EQUIPMENT(Required) 490-69c. ❑ CALIFORNIA UNDERGROUND STORAGE TANK REGULATIONS 490-69d. ❑ CALIFORNIA UNDERGROUND STORAGE TANK LAW 490-69e. ❑ STATE WATER RESOURCES CONTROL BOARD (SWRCB) PUBLICATION: "HANDBOOK FOR TANK OWNERS - MANUAL AND 490-69f. STATISTICAL INVENTORY RECONCILIATION" E] SWRCB PUBLICATION:"UNDERSTANDING AUTOMATIC TANK GAUGING SYSTEMS" 490-698. C] OTHER(Specify): 490 -69. ® This facility has a"Designated UST Operator"who has passed the California UST System Operator Exam administered by the International Code Council 490-70. (ICC). The "Designated UST Operator"will train facility employees in the proper operation and maintenance of the UST systems annually,and within 30 days of hire.This training will include,but is not limited to,the following: ➢ Operation of the UST systems in a manner consistent with the facility's best management practices. ➢ The facility employee's role with regard to the monitoring equipment as specified in this UST Monitoring Plan. ➢ The facility employee's role with regard to spills and overfills as specified in the facility's UST Response Plan. ➢ Name(s)of contact person(s)for emergencies and monitoring alarms. X. COMMENTS/ADDITIONAL INFORMATION Provide addit c l-c niments hcri or ate how many ges wit Tdtional info ation on pecific nniitoring procedures are �c o this plan. 490-71. = 1 t t f. XI. PER ONNEL RESPONSIBILITIES The UST Owner/Operator is responsible for ensuring that: 1.)the daily/routine UST monitoring activities and maintenance of UST leak detection equipment covered by this plan occurs-,2.) 11 conditions that indicate a possible release are investigated;and 3.)all monitoring records are maintained properly. _ __ THE FOLLOWIN ERSON(S)ARE RES O IBLE FO"RRFORMING THE MONITORING A EQUIPME T MAINTENANCE: / a91 � t 490-71NAME: NAME: 1 490.74. TITLE: V.)C--C_ L' ! L 490-75, The Designated UST Pfkrator shall perform a monthly visual inspection of the facility,provide a report to the o er/operator,and inform the owner/operator of any conditions that needtollow-up action. XII. OWNEWgPLHUTOR SIGNATURE CERTIFICATION:I certify that to)k1rinagion provi ederein is true and accurate to the best of my kqowledge. APPLICANT SIGNATURE DATE: �r 0-90-77. REPRESENTING:0 t.Tank Owner/G or 0 .Facifi O r/O erator 0 3.Authorized Re mentative of Owner 490-76. ( � - APPLICANT NAME(print): 490-78. APPLICANT TI E: 490.79. UPCF UST-D(12/2007)-3/4 www.Unidocs.org