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UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK MONITORING PLAN- age 1 of 2 TYPE OF ACTION 21T.NEW PLAN [12.CHANGE OF INFORMATION 490-1. PLAN TYPE 99-1.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) 1 -111 IIIE: BU INESS NAME(Same as Facility Name or DBA) 3 eA)c.(P c N(1 i`(l to C s BUSINESS SITE ADDRESS 103, 1 CITY 104. 1G/C j4wry.. 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 bxthe_equipment manufacturers'instructions,or annually,whichever is more frequent.Such work must be performed by qualified personnel.[23 CCR§2632,2634,2638,2641] 490.3& MONITORING EQUIPMENT IS SERVICED M'T ANNUALLY ❑ 99.OTHER(Specify): 490-3b. M. MONITORING LOCATIONS ❑ 1.NEW SITE PLOT PLAN/MAP SUBMITTED WITH THIS PLAN ®'2.SITE PLOT PLAN/MAP PREVIOUSLY SUBMITTED490-0. [23 CCR§2632,2634] IV. TANK MONITORING IS PERFORMED USING THE FOLLOWING METHOD(S) (check-" CONTINUOUS ELECTRONIC TANK MONITORING OF ANNULAR(INTERSTITIAL)SPACE(S)OR SECONDARY CONTAINMENT VAULT(S) 490-5. WITH AUDIBLE AND VISUAL ALARMS.[23 CCR§2632,26341 SECONDARY CONTAINMENT IS: [$�C DRY ❑ b.LIQUID FILLED ❑ c.PRESSURIZED ❑ d.UNDER VACUUM 490-6. PANEL MANUFACTURER: (, D EfL 490-7 MODEL#: .04 ��S 3 90-8, LEAK SENSOR MANUFACTURER: /�"[�"�,� O Y 490-9. MODEL#(S): ��-/'� 490-10 ❑ 2.AUTOMATIC TANK GAUGING(ATG)SYSTEM USED TO MONITOR SINGLE WALL TANK(S).[23 CCR§26431 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-I6. ❑ 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 123 CCR§2646.11 490-20. ❑ 4.WEEKLY MANUAL TANK GAUGING(MTG)123 CCR§26451 TESTING PERIOD: ❑ a.36 HOURS ❑ b.60 HOURS49x21. 490-21 ❑ 5.TANK INTEGRITY TESTING PER[23 CCR§2643.11 490-23. 490-24. TEST FREQUENCY: ❑ a.ANNUALLY ❑ b.BIENNIALLY ❑ c.OTHER(Specify): 490-25. ❑ 99.OTHER(Specify): 490-26.- a90-7.7. V. PIPE MONITORING IS PERFORMED USING THE FOLLOWING METHOD(S) r0-ht,,k Ill EjT CONTINUOUS MONITORING OF PIPE/PIPING SUMP(S)AND OTHER SECONDARY CONTAINMENT WITH AUDIBLE&VISUAL ALARMS. 490-28. g1 CC SECONDARY CONTAINMENT IS: [�a.DRY Elb.LIQUID FILLED ❑ c.PRESSURIZED ❑ d.UNDER CUUM 490-29. PANEL MANUFACTURER: v L-'�D CA ®l 490-30. MODEL#: �f®S 'r3 490-31 LEAK SENSOR MANUFACTURER: jZ ®T 412. MODEL#(S): 'dN'® 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. 9-15.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 490-36. PRODUCT FLOW WHEN A LEAK ISDETECTED.[23 CCR§2636] / MLLD MANUFACTURER(S): �49aa7. MODEL#(S): y L-® 49x38. ❑ 3.ELECTRONIC LINE LEAK DETECTOR(ELLD)THAT ROUTINELY PERFORMS 3.0 g.p.h.LEAK TESTS.123 CCR§26361 490-39, ELLD MANUFACTURER(S): 490-40. MODEL#(S): 49041. PROGRAMMED IN LINE LEAK TEST: ❑ a.MINIMUM MONTHLY 0.2 g.p.h. ❑ b.MINIMUM ANNUAL 0.1 g.p.h. 49042. ELLD DETECTION OF A PIPING LEAK TRIGGERS AUTOMATIC PUMP SHUTDOWN. ❑ a.YES ❑ b.NO 490-43. ELLD FAILURE/DISCONNECTION TRIGGERS AUTOMATIC PUMP SHUTDOWN. ❑ a.YES ❑ b.NO 490-0-4. ❑ 4.PIPE INTEGRITY TESTING. 490-45. TEST FREQUENCY: ❑ a.ANNUALLY [3490-46. b.EVERY 3 YEARS ❑ c.OTHER(Specify) 490,{7. ❑ 5.VISUAL PIPE MONITORING. 49048. FREQUENCY: ❑ a.DAILY ❑ b.WEEKLY ❑ c.MIN.MONTHLY&EACH TIME SYSTEM OPERATED* 49049. *Allowed for monitoring of unburied emergency generator fuel ung only Per HSC ❑ 6.SUCTION PIPING MEETS EXEMPTION CRITERIA.[23 CCR§2636(x)(3)] 490-50. ❑ 7.NO REGULATED PIPING PER HEALTH AND SAFETY CODE,DIVISION 20,CHAPTER 6.7 IS CONNECTED TO THE TANK SYSTEM. 490-51. El99.OTHER(Specify) 49x52. 49453. UPCF UST-D(12/2007)-1/4 www.unidoes.org