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UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK MONITORING PLAN - (Pae 1 of 2) TYPE OF ACTION 9?'1. NEW PLAN ❑ 2. CHANGE OF INFORMATION 490-1. PLAN TYPE F!t^"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 BUSINESS NAME (Same as Facility Name or DBA) 3. RA) Lrr-Ic M®N► MPq 4 s BUSINESS SITE ADDRESS 103. CITY 104, SII C -t Pie vc� �- II. 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 equi ment manufacturers' instructions, or annual, whichever is more frequent._ Such work must be performed by qualifie�rsonnel. [23 CCR §2632,2634,2638,26411 MONITORING EQUIPMENT IS SERVICED WTI. ANNUALLY 99. OTHER490-3a. Q LQ ❑ (Specify): 490-36. III* MONITORING LOCATIONS ❑ 1. NEW SITE PLOT PLAN/MAP SUBMITTED WITH THIS PLAN [R'2. SITE PLOT PLAN/MAP PREVIOUSLY SUBMITTED 123 CCR §2632, 2634] 4904. IV. TANK MONITORING IS PERFORMED USING THE FOLLOWING METHOD(S)(Check a[[ that apply) 1. CONTINUOUS ELECTRONIC TANK MONITORING OF ANNULAR (INTERSTITIAL) SPACE(S) OR SECONDARY CONTAINMENT VAULT(S) 4 - WITH AUDIBLE AND VISUAL ALARMS. [23 CCR §2632,26341 SECONDARY CONTAINMENT IS: [tea DRY ❑ b. LIQUID FILLED ❑ c. PRESSURIZED ❑ d. UNDER VACUUM 490-6. PANEL MANUFACTURER: (e ag D E r 490-7. MODEL #: '%`.S 3 90$' LEAK SENSOR MANUFACTURER: // A5V A p T 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 490-16. ❑ d. MONTHLY ❑ e. OTHER (Specify): 490-17. PROGRAMMED TESTS: ❑ a. 0.1 g.p.h. [Ib. 0.2 h. ❑ c. OTHERcif 490-18. g•P• (Specify): ago -re. ❑ 3. MONTHLY STATISTICAL INVENTORY RECONCILIATION [23 CCR §2646.11 490-20. El WEEKLY MANUAL TANK GAUGING (MTG)123 CCR §26451 TESTING PERIOD: C]a. 36 HOURS ❑ b. 60 HOURS amizz z 1. .4. ❑ 5. TANK INTEGRITY TESTING PER 123 CCR §2643.11 490-23. 490-24. TEST FREQUENCY: ❑ a. ANNUALLY ❑ b. BIENNIALLY ❑ c. OTHER (Specify): 490-25. E]99. OTHER (Specify): 490-26. 490-z7. V. PIPE MONITORING IS PERFORMED USING THE FOLLOWING METHOD(S) has ack Ill [Vr CONTINUOUS MONITORING OF PIPE/PIPING SUMP(S) AND OTHER SECONDARY CONTAINMENT WITH AUDIBLE & VISUAL ALARMS. 490-28. [23 §26361 SECONDARY CONTAINMENT IS: &a. DRY ❑ b. LIQUID FILLED Elc. PRESSURIZED ❑® d. UNDER CUUM 490-29. PANEL MANUFACTURER: �% p FiA Pvo l 490.30. MODEL #: �LS 490-31. LEAK SENSOR MANUFACTURER: ®-� a� 3z. MODEL #(S): O 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. 9005. YES ❑ b. NO 490-35. 52'12. 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 �/ rte/ `-® 49038. -1 f490-37. MODEL #(S) ( T MLLD MANUFACTURER(S): / EO J V IM I ❑ 3. ELECTRONIC LINE LEAK DETECTOR (ELLD) THAT ROUTINELY PERFORMS 3.0 g.p.h. LEAK TESTS. [23 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 49043. ELLD FAILURE/DISCONNECTION TRIGGERS AUTOMATIC PUMP SHUTDOWN. ❑ a. YES ❑ b. NO 490 ❑ 4. PIPE INTEGRITY TESTING. 490-45. 490-46. TEST FREQUENCY: ❑ a. ANNUALLY ❑ b. EVERY 3 YEARS ❑ c. OTHER (Specify) 49047. ❑ 5. VISUAL PIPE MONITORING. 490-48. FREQUENCY: ❑ a. DAILY ❑ b. WEEKLY ❑ C. MIN. MONTHLY & EACH TIME SYSTEM OPERATED* 490-49. * Allowed for nronitoring of unburied emergency generazor fuel piping only per HSC ?t25281. (b)(3)_ ❑ 6. SUCTION PIPING MEETS EXEMPTION CRITERIA. [23 CCR §2636(a)(3)1 490-30 ❑ 7. NO REGULATED PIPING PER HEALTH AND SAFETY CODE, DIVISION 20, CHAPTER 6.7 IS CONNECTED TO THE TANK SYSTEM. 490-51. 490-�i.- riff 99. OTHER (Specify)ago-s3. -53. UPCF UST -D (12/2007) -1/4 www.unidocs.org