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Home My WebLink AboutSLOUNIFLOW_FS1 Admin iRC3926i Color_0170_001San Luis Obispo County FORM I Material Inventory Form -iemical Description Page .\ r, -Zardous (1)Xaoo l-loelEre ll nevtse PAGE OF1 5 BUSINESS NAME: United Parcel Service cHEMTCAL LOCATTON (4) MAP # (5)GR|D # (6)K7 CHEMICAL LOCATION IS CO NFIDENTIAL AND NOT SUBJECT TO PUBLIC DISCLOSURE 1 cHEMTCAL NAME (7) coMMoN NAME (B) cAS # (e) TYPE (12) PHYSICAL STATE (13) HMARD CATEGORIES (16) STATE WASTE CODE (17) DAYS ON SlrE (18) LARGEST CONTAINER (19) STORAGE CONTAINER (24) SToRAGE PRESSURE (25) STORAGE TEMPERATURE (26) ZT 100 %WT HAZARDOUS Waste Aerosols Lab Pack -Generated waste N/A PURE RE Xsolro l-l-rouro l-lons TRADE SECRET (10) EHS (11) N/A N/A RADTOACTIVE (14)(1 5) rrnr flReecrve PRESSURE RELEASE HEALTH HEALTH ncnr- Ecu rr XLas l-lrons Ev Xu MAX DAILY AMT (21) AVG DAILY AMT (22) ANNUAL WASTE AMT (23) IF EHS BOX IS "Y" ALL AMOUNTS MUST BE IN LBS pCURIES g5 55 100 NiA 365 55 UNrTS (20) IENT AMBIENT ELOW AMBIENT IENT AMBIENT AMBIENT IC EHS lf EHS amounts must be in lb. NT CAS NUMBER 1 2 3 4 5 GROUND TANK WAGON leElow cRouND TANK lrnur TNSTDE BUTLDTNG Xsreel onuv ncnnsov INDER CAR Esro nnarR onuu nonss BorrLE BOTTLE DRUM BIN D001, D002, D005, D006, D007, u240 !v Xru l-lY l-l tt l-lv l-]ru llv nu l-lv l-ltrt (31) ADDTTTONAL LOCALLY COLLECTED INFORMATION Adapted from OES Ronn2730 07/12/10 O:\docurnent\poel\fonns\wastanti.doc San Luis Obispo County ^-)u.Uorm FORM I Material Inventory Form -iemical Description Page (1)Xnoo noelere n nevtse PAGE OF2 5 United Parcel ServiceBUSINESS NAME: cHEMTCAL LOCATTON (4) MAP # (5) --.- ut lgu GR|D # (6)K7 CHEMICAL LOCATION IS CONFIDENTIAL AND NOT SUBJECT TO PUBLIC DISCLOSURE 1 CHEMICAL NAME (7) coMMoN NAME (8) cAs # (e) TYPE (12) PHYSICAL STATE (13) HMARD CATEGORIES (16) STATE WASTE CODE (17) DAYS ON SITE (18) LARGEST CONTAINER (19) SToRAGE CONTATNER (24) STORAGE PRESSURE (25) SToRAGE TEMPERATURE (26) Waste Corrosive Lab Pack - Packaqe Generated waste N/A Epune flvrxruRe Xwnsre SOLID LIQUID RADTOACTTVE (14) TRADE SECRET (10) !v Xr.r (1 5) MAX DAILY AMT (21) AVG DA|LY AMT (22) ANNUAL WASTE AMT (23) N/A EHS (11)N/A IF EHS BOX IS "Y' ALL AMOUNTS MUST BE IN LBS pCURIES 70 50 100 Xrtne REACTIVE RELEASE HEALTH HEALTH 181 365 55 UNrTS (20) ncnl ncu rr XLes l-lrorus lf EHS amounts must be in lb. IENT AMBIENT BELOW AMBIENT IENT AMBIENT BELOW AMBIENT CRYOGENIC zt 100 %WT 1 2 3 4 5 COMPONENT D002 EHSzv Ev Xtl [-lv nru Ev llt nv nru [lY l-ltt 3U CAS NUMBER GROUND TANK CAN WAGON !eelow GRoUND TANK nrnrux TNSTDE BUTLDTNG !cnnaoY lsrr-o Ecvlrruoen lcmss BorrLE Eplnsrtc BorrLE lnnt cen DRUM FIBER DRUM BAGC DRUM BIN (31) ADDITIONAL LOCALLY COLLECTED INFORMATION Adapted frorn OES Fonn 2730 07/12/10 O :\docurnent\poel\forms\wastanti.doc San Luis Obispo Counfy r,)utOoo, FORM I Material Inventory Form -.lemical Description Page (1)Xnoo loelere E nEvse PAGE OFJ 5 United Parcel ServiceBUSINESS NAME: cHEMTCAL LOCATTON (4) MAP # (5) F GRrD # (6)K7 CHEMICAL LOCATION IS CON FIDENTIAL AND NOT SUBJECT TO PUBLIC DISCLOSURE 1 cHEMTCAL NAME (7) coMMoN NAME (8) cAS # (e) TYPE (12) PHYSTCAL STATE (13) HMARD CATEGORIES (16) STATE WASTE CODE (17) DAYS ON S|TE (18) LARGEST CONTAINER (19) SToRAGE CONTAINER (24) SToMGE PRESSURE (25) STORAGE TEMPEMTURE (26) ZI 100 %WT HAZARDOU Waste Flammable ds Lab Pack -Generated waste N/A l-lpune l-lurxrune Xwesre nsouo Xltouto lcns TRADE SECRET (10) EHS (11) N/A N/A RADTOACTTVE (14)(1 5) FIRE RE RELEASE HEALTH HEALTH 135 365 If EHS amounts must be in lb. 55 BIENT AMBIENT AMBIENT OVE AMBIENT AMBIENT Nrc lcnl ncu rt XLss flrous l-lv Xu MAX DA|LY AMT (21) AVG DA|LY AMT (22) ANNUAL WASTE AMT (23) IF EHS BOX IS'Y" ALL AMOUNTS MUST BE IN LBS pCURIES 55 30 BO UNrTS (20) NT 1 2 3 4 5 EHSzv !v Xru nv nru l-lv l-lt't nv nru l-lv lltt NUMBER GROUND TANK BOX CYLINDER ANK WAGON f]eElow cRouND TANK nrnrur rNsrDE BUTLDTNG Xsreel onuut EcnnaoY Esrlo lnnt cnn DRUM f]cmss BorrLE Epnslc BorrLE PLASTIC/NONMETALLIC DRUM BIN D001. D039 (31) ADDTTTONAL LOCALLY COLLECTED INFORMATION Adapted from OES Fonn 2730 07/12/10 O :\docurnent\poel\fonns\wastanti.doc San Luis obispo County i^l)u.aoo, FORM I Material Inventory Form -lemical Description Page (1)DELETE REVISE PAGE OF4 5 United Parcel ServiceBUSINESS NAME: cHEMTCAL LOCATTON (4) MAP # (5)GRID # (6)K6 CHEMICAL LOCATION IS CONFIDENTIAL AND NOT S UBJECT TO PUBLIC DISCLOSURE ,| ncHEMTCAL NAME (7) coMMoN NAME (8) cAS # (e) TYPE (12) PHYSTCAL STATE (13) HMARD CATEGORIES (16) STATE WASTE CODE (17) DAYS ON S|TE (18) LARGEST CONTAINER (19) STORAGE CONTAINER (24) STORAGE PRESSURE (25) STORAGE TEMPERATURE (26) n N/A l-lsolro l-luouto Xcns TRADE SBCRET (10) EHS (11)N/A RADTOACTTVE (14)(1 5) RE REACTIVE PRESSURE RELEASE HEALTH CHRONIC HEALTH lf EHS amounts must be in lb. nv Xu MAX DA|LY AMT (21) AVG DAILY AMT (22) ANNUAL WASTE AMT (23) IF EHS BOX IS "Y' ALL AMOUNTS MUST BE IN LBS pCURIES 281 55 CAS NUMBER UNrTS (20) ncnr- Xcu rr l-llas I lrous 365 281 NT AMBIENT ELOW AMBIENT NT AMBIENT NETLOWAMBIENT RYOGENIC 1 2 3 4 E HAZARDOUS COMPONENTz6 oxyqen EHS []v Xtt nv nru l-lv Etl l-lY l-ltrt !Y nru 0 GROUND TANK K WAGON EeeLow GRoUND TANK nrnur rNsrDE BUILDTNG Esreel oRul,l ncnneov R RAIL CAR DRUM f]cuss BorrLE npnslc BorrLE PLASTIC/NONMETALLIC DRUM BIN 100 (31) ADDTTTONAL LOCALLY COLLECTED INFORMATION Adapted from OES Fonn 2730 0'7/l2ll0 O :\docurnent\jpoelVorms\wastanti.doc San Luis obispo County i,)u.aoo, FORM I Material Inventory Form lemical Description Page Xnoo l-lprlere fl nevse PAGE OF(1)5 5 United Parcel ServiceBUSINESS NAME: cHEMTCAL LOCATTON (4) MAP # (5)GRrD # (6)t3 CHEMICAL LOCATION IS CONFIDENTIAL AND NOT SUBJECT TO PUBLIC DISCLOSURE 1 cHEMTCAL NAME (7) coMMoN NAME (8) cAS # (e) TYPE (12) PHYSTCAL STATE (13) HMARD CATEGORIES (16) srATE WASTE CODE (17) DAYS ON SITE (18) LARGEST CONTATNER (19) STORAGE CONTAINER (24) STORAGE PRESSURE (25) STORAGE TEMPERATURE (26) zt 75% 1% %WT oir Lubri oil N/A RE MIXTURE l-lsouo Xuouro l-'lons uNrTs (20) 365 lf EHS amounts must be in lb. 250 RADTOACTTVE (14)(1 5) FIRE REACTIVE PRESSURE RELEASE UTE HEALTH HRONIC HEALTH TRADE SECRET (10) l-lv Xru MAX DAILY AMT (21) AVG DAILY AMT (22) ANNUAL WASTE AMT (23) NiA EHS (11)N/A IF EHS BOX IS'Y" ALL AMOUNTS MUST BE IN LBS pCURIES 250 55 1000 qallons BIENT AMBIENT BELOW AMBIENT IENT AMBIENT BELOW AMBIENT ENIC 1 2 3 4 5 COMPONENT Lubricatinq base oils zinc alkvl dithiophosphate zvl tr Ilv Xtrt l-lv l-|ru nY !n nv nu l-lv l-ltt CAS R CU FT GROUND TANK WAGON BELOW GROUND TANK ncYuruorn lcmss BorrLE Epnslc BorrLE nnnt cnn nrnrux rNsrDE BUTLDTNG !str-o Erraen onuptSTEEL DRUM PLASTIC/NONMETALLIC DRUM BAG BIN 6474-18-84 N/A (31) ADDTTIONAL LOCALLY COLLECTED INFORMATION Adapted from OES Fonn2730 0'1112/10 O :\docurnent\poel\fonns\wastanti.doc L. ,IFIED PROGRAM CONSOLIDATED F'O' UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION _ FACILITY INFORMATION (One fonn per facility) TYPE OF ACTION (Check one item only) E I, NeW PERMIT ! 3. RENEWAL PERMIT X 5. CHANGEOF INFORMATION ! E. TSVPONERY FACILITY CLOSURE ! 7. PERMANENT FACILITY CLOSURE E 9. TRANSFER PERMIT 400. I. FACILITY INFORMATION l. 4 8 1 0FA000FACILITY ID # (Agency Use Only) TOTAL NUMBER OF USTS AT FACILITY 1 404. BUSINESS NAME (Same a FACILITY NAME or DBA Doing Busines As) United Parcel Service 3. 104.CITY San Luis Obispo BUSINESS SITE ADDRESS 3601 Sacramento Dr 103. 405. Is the facility located on Indian Reservation or Trust lands? E Yes E NoX I. MOTOR VEHICLE FUELING n :. renv E 4. PRocESSoR FACILITY TYPE 403.E 2, FUEL DISTRIBUTION 6. OTHER U. PROPERTY OWNER INFORMATION (213) 612-1924 408.PHONEPROPERTY OWNERNAME United Parcel Service 407. 4t6. MAILING ADDRESS 16000 Arminta St. ZIP CODE 91406 419.418.STATE CAVan Nuys 41'lCITY III. TANK OPERATOR INFORMATION (805) 544-7184 428-2PHONETANK OPERATOR NAME United Parcel Service 428-t MAILING ADDRESS 3601 Sacramento Dr 428-1 ZIP CODE 93401 428-6STATE428-5 CA CITY San Luis Obispo 428-4 IV. TANK OWNER INFORMATION (213) 612-1924 4t5.PHONETANKOWNERNAME United Parcel Service 414 MAILING ADDRESS 16000 Arminta St. 416. 4 t8.STATE CA 4t9ZIP CODE 91 406 4t'l Van Nuys CITY E 4. LOCAL AGENCY/DISTRICT E T.FEDERALAGENCY ! 5.COUNTYAGENCY X 8. NON-GOVERNMENT E e. srereAGENCYOWNERTYPE: 420. v. BOARD OF EQ UALIZATION UST STORAGE FEE ACCOUNT NTIMBER 3 I 2 2 4 Call the State Board of Equalization, Fuel Tax Division, ifthere are questions 42t rY (rK) HQ 44-0 VI. PERMIT IIOLDER INFORMATION Issue pennit and send legal notifications and rnailings to:E 1. FACILITY OWNER X 3. TANKoWNER E 4.TANKOPERATOR E 5, FACILITY OPERATOR 423 supERVISOR OF DIVISION, SECTION, OR OFFICE (Required For Public Agencies only) that 424.DATET ta'aND accur and in fullCERTIFIC VII. APPLICANT SIGNATT]RE herein is 947-483r uirements.with PHONE 81 APPLICANT S APPLICANT TITLE President 427 APPLICANT NEMK(FTint) Noel Massie 426 UPCF UST-A Rev. (1212007) UST Operating pr'-\t Application - Facility Informatio )age 1 Instructions (tr'ormerly SWRCB UST Permit Application Form A and UPCf,'Form hwfwrc-a) Cornplete this fonn for all new permits, pennit changes, or facility information changes. This form must be subrnitted within 30 days of permit or facility infonnation changes, unl"r. your local agency requires approval prior to making the changes. For changes, submit only that form that contains the change. Subrnit one UST Operating Pennit Application - Facility Infonnation fonn per facility,-regardless of the number of USTs.located at the facility. If not alr€ady on file wiih the lial ug"n.y, th" tank owner must submit with this fornq a current UST Operating Permit Application -Tank Information fomt for each UST; a UIT Monitoring plan aad -a UiT nesponse Plan pursuant to 23 CCR 2632, 2634 and 2641; and, for USTs containing petrcl€utr, a oErtification of financial responsibility pursuant to 23 CCR 2807. The following documents, at a minirnurn, are also required, if applicable (check with your local agency to see if they require submittal or if there are other fonns/infonnation needed): D Written agreement between UST Owner and UST Operator per Health and Safety Code $2528a(aX3); tr Letter ffom the Chief Financial Officer (if using State Cleanup Fund, financial test of self-insurance, guarantee, local government ltnancial test, or Local Governtnent Fund as a financial responsibility mechanisln)' Please nurnber all pages of your subrnittal. (Note: Nurnbering of these inshuctions matches the data eletnent numbers on the fonn.) 1 04. 403. 405. 40'1. 408. 409. 410. 41t. 412. 428-1. 428-2. 428-3. 428-4. 428-5. 428-6. 414. 415. 416. 417. 41 8. 419. 420. 421. 400. 404. l 3. 1 03. 423. 406. 424. 42s. 426. 427. TYPE OF ACTION - Check the reason this fonn is being subrnitted. CHECK ONE ITEM ONLY. TOTAL NUMBER OF USTs AT SITE - Indicate the nutnber of tanks that will remain on the site after the requested action. FACILITY ID NUMBER - This space is for agency use only. BUSINESS NAME - Enter the complete Business Name. (Sarne as FACILITY NAME or DBA (Doing Business As)). BUSINESS SITE ADDRESS - Enier the street address of the facility, including building number, if applicable. This address Inust be the physical location of the facility. Post office box numbers are not acceptable. CITY - Enter the city or unincorporated area in which the facility is located. FACILITY TYPE - Indicate the type of facility. INDIAN RESERVATION OR TRUST LANDS - Check whether the facility is located on an Indian reservation or other trust lands' PROPERTY OWNER NAME - Cornplete iterns 407 - 412 for the property owner. Include the area code and any PROPERTY OWNER PHONE - extension number. PROPERTY OWNER MAILING ADDRESS - PROPERTY OWNER CITY _ PROPERTY OWNER STATE_ PROPERTY OWNER ZIP CODE _ TANK OPERATOR NAME - Complete iterns 428-l to 428-6 for the UST operator. TANK OPERATOR PHONE - Include the area code and any extension number. TANK OPERATOR MAILING ADDRESS - TANK OPERATOR CITY * TANK OPERATOR STATE- TANK OPERATORZIP CODE_ TANK OWNER NAME - Cornplete items 414 - 419 for the UST owner. TANK OWNER PHONE - Include the area code and any extension number. TANK OWNER MAILING ADDRESS - TANK OWNER CITY _ TANK OWNER STATE_ TANK OWNER ZIP CODE_ TANK OWNER TYPE - Check the type of tank ownership. BOE NUMBER - Enter your State Board of Equalization (BOE) UST storage fee account number. This fee applies to regulated USTs storing petroleurn producti and is required before your pennit application will be processed. If you do not have an account nutnber with the BOE,;; if you have any questions regarding the fee or exernptions, contact the BOE at (916) 322-9669 or by mail at: Board of Equalization, Fuel Taxes Division, PO Box 942879, Sacratnento, CA 94279-0030. PERMIT HOLDER INFORMATION - Indicate the party to whom the UST operating permit is to be issued and legal notifications and rnailings should be sent. SUPERVISOR OF DIVISION SECTION OR OFFICE SUPERVISOR - If the facility owner is a public agency, enter the name of the supervisor ofthe division section or office that operates the UST. This person rnust have access to the UST records. APPLICANT SIGNATURE - The application fonn must be signed, in the space provided, by: r The UST owner or operator, facility owner or operator, or a duly authorized representative ofthe owner; or r If the UST(s) is/are owned by a corporation, partnership, or public agency: l.) A principal executive oifi"". ut the level ofvice-president or by an authorized representative responsible for the overall operation of the facility where the UST(s) is/are located; or 2.) A general partner or proprietor; or 3.) A principal executive officer, ranking elected official, or authorized representative ofa public agency. DATE - Enter the date the fonn was signed. PHONE - Enter the phone nurnber of the applicant (i.e., person signing the fonn). Include the area code and any extension number. APPLICANT NAME - Print or type the full narne of the person signing the fonn. APPLICANT TITLE - Enter the title of the person signing the fonn. UPCF UST-A Rev. (1212007) {IFIED PROGRAM CONSOLIDATED F/ UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION - TANK INFORMATION (onefonn UST pennanent closure or tetnoval, complete 3. RENEWAL PERMIT 7. UST PERMANENT CLOSURE ON SITE only this section and Sections I, II, III, IV, and IX below) X 5. CHANGEOF INFORMATION 430 anForoneOFTYPEACTIONonly(Check 8. UST REMOVAL DATE EXISTING UST DISCOVERED:DATE UST PERMANENTLY CLOSED I. NEW PERMIT 6. TEMPORARY UST CLOSURE I. FACILITY INFORMATION B 1 0A0004FFACILITY lD # (Agency Use Only) BUSINESS NAME (Sarne as FACILITY NAME or DBA-Doing Business 1A.) United Parcel Service CITY San Luis Obispo 104 BUSINESS SITE ADDRESS 3601 Sacramento Dr. 103 U. TANK DESCRIPTION TANK CONFIGURATION: THIS TANK IS X LasraNo-aloNETANK [ 2. oNE rN A CoMPARTMENTED LINIT . Conolete one page for each compafrment in the unit. 434TANK MANUFACTURER Owens Coming 433432TANK ID # Diesel #l NUMBER OF COMPARTMENTS IN THE UNIT 437TANK CAPACITY IN GALLONS 10.000 436435DATE UST SYSTEM INSTALLED 08/l 5/l 989 X Ia. IUOTOR VEHICLE FUELING ! 3. CHEMICAL PRODUCT STORAGE E 6, OTHER GENERATOR FUEL E Ib. MARTNA FUELING ! 4. HAZARDOUS WASTE (lncludes Used Oil) E 95. trNKNowN E Ic, AVIATION FUELING E 5. EMERGENCY GENERATOR FUELIHSC 925281.5(c)l TANK USE 439 III. TANK USE AND CONTENTS 439aE 99. orHER Ic. MIDGRADE UNLEADED 5. JET FUEL 9, OTHER PETROLEUM NON.PETROLEUM CONTENTS PETROLEUM: IO. ETHANOL 8. PETROLEUM BLEND FUEL 440a 440b I Ib. PREMIUM UNLEADED ! 6. AVIATION GAS E la. REGULAR LINLEADED E 3, DIESEL 7. USED OIL I I. OTHER NON-PETROLEUM D I. SINGLE WALL 2. DOUBLEWALL E 95. UNKNOWN I, STEEL 3. FIBERGLASS 7, STEEL + INTERNAL LINING ryPE OFTANK PRIMARY CONTAINMENT 443 444a IV. TANK CONSTRUCTION 6. INTERNAL BLADDER 95. UNKNOWN ! 99. OTHER 445 445a 7, JACKETED6. EXTERIOR MEMBRANE LINERI. STEEL I gs. orHsnE go. NoNp 3. FILL TUBE SHUT-OFF VALVE2. BALL FLOAT1. AUDIBLE & VISUAL ALARMS FOR EXEMPTION FROM OVERFILL PREVENTION4. TANK MEETS SECONDARY CONTAINMENT OVERFILL PREVENTION 3. FIBERGLASS 95. UNKNOWN V. PRODUCT / WASTE PIPING CONSTRUCTION ! so. NoNE. ccR IO. RIGID PLASTICSECONDARY CONTAINMENT 3. CONVENTIONAL SUCTION 8. FLEXIBLE 99. 8. FLEXIBLE I. PRESSURE I. STEEL 2, GRAVITY 4. FIBERGLASS E 95.UNKNOWN 464a 464c 10. RIGID PLASTIC 4- SAFE SUCTIONSYSTEM TYPE PRIMARY CONTAINMENT ! 99. orHER I, STEEL 90. NONE 4. FIBERGLASS 95. UNKNOWN 90. NONE2. DOUBLE WALLE 1. SINGLE WALLPIPING/TURBINE CONTAINM ENT SUMP TYPE vI. VENT, VAPORRECOVERY (VR)AND RISER/ FILL PIPE PIPING CONSTRUCTION 90. NONE 90. NONE 90. NONE 90. NONE 4. FIBERGLASS 4- FIBERGLASS 4. FIBERGLASS 4. FIBERGLASS IO. RIGID PLASTIC IO. RIGID IO. RIGID PLASTIC 10.D PLASTIC VR SECONDARY CONTAINMENT VR PRIMARY CONTAINMENT VENT PRIMARY VENT Y CONTAINMENT 99. OTHER (Specifr) 99. OTHER 99.(Specify) OTHER (Speciry) STEEL STEEL STEEL STEEL 464ft 464g 464h 464h1 2, DOUBLE WI- SINGLE WVENT PIPING SIJMP NONE 90. 4. 4. FIBERG 99. OTHER 99. OTHER IO, RIGID PLASTIC IO. RIGID PLASTIC I- STEEL I. STEEL RISER PRIMARY CONTAINMENT RISER SECONDARY CONTAINMENT 464k 464kt FILL COMPONENTS INSTALLED I. SPILL BUCKET 3. STRIKER PLATE/BOTTOM PROTECTOR 4. CONTAINMENT SUMP 45 la-c fl so. ttoNp 469a3. NO DISPENSERS 99. OTHER CONSTRUCTION TYPE CONSTRUCTION MATERIAL VII. UNDER DISPENSER COI'{TAINMENT 2. DOUBLE WALLEI I. SINGLE WALL IO. RIGID PLASTIC4. FIBERGLASSI. STEEL STEEL COMPONENT PROTECTION CERTIFICATION: I certify and in DATE 2-tA-AotoAPPLICANT with the hazardous substance stored and that the information provided hcrein is truer accuratet VUI. CORROSION PROTECTIOI{ E 6. ISOLATIONE 4. IMPRESSEDCURRENTE 2. SACRIFICIAL ANODE(S) IX. APPLICANT SIGNATURE this UST system rvith APPLICANT TITLE President 472. APPLICANTN AMP.@nri6 4'1t. Noel Massie L / UPCF UST-B. I/2 Rev. (1212007) UST Operating Permit Applicaf'' "'1- Tank Information Instructions '--'\ (Fonnerly SWRCB Pennit Application Fonn u and UPCF Fonn hwfwrc-b) Complete a separate fonn for each UST for all new pennits, pennit changes, and any UST system infonnation changes. This form must be submitted within 30 days of p.r.r1it o. UST system infonnation changes, unless your local agency requires appioval prior to making changes. For tanks that are part of a comparttnentalized unit, Lach comparlrnent is considered a separaie tank and requires completion of a separate Tank Infonnation fonn. For a UST pennanent closure or removal, cornplete only TypE OF ACTION and Sections I, II, III, IV, and IX. (Note: Numbering of these instructions matches the data element numbers on the fonn.) TypE OF ACTION Check the appropriate box to indicate why this fonn is being subrnitted. DATE UST PERMANENTLY CT SED - f or repofting closure only: enter the date the UST was removed or closed on site. DATE EXISTING UST DISCOVERED - Enter the date this UST was discovered. Leave blank if installation date is known. FACILITY ID NUMBER - This space is for agency use only. BUSINESS NAME - Entel the cornplete facility natne. BUSINESSSITEADDRESS-Enterthestreetaddressofthefacility,includingbuildingnurnber,ifapplicable. Thisaddressmustbethephysicallocationof the facility. Post office box nutnbem are not acceptable. CITY - Enter the city or unincorpomted area in which the facility is located. TANK ID # -Applicant may entei the ownsr's tank identification number or leave this space blank. The Local Agency will assign the State taxk identification number as the unique idortifier for the tank. 430. 430a. 430b. l. 3. 103. 104. 432 433 , TANK MANUFACTURER - Enter the name of the cornpany that manufactured the tank. 434. TANK CONFIGURATION. Check the appropriate box to indicate if the tank is a stand-alone tank or one in a cornpartlnented unit. A sepamte UST Operating pennit Application - Tank Infonnation fonn must be subrnitted for each compartment. 435. DATE UST SYSTEM INSTALLED Enter the date the local agency signed-off on installation of the UST systern. This is the date of initial tank systetn installation, and does not include upgrades or retrofits which rnay have been pedonned later. If this is for a new installation, leave blank. 436. TANK CAPACITY IN GALLONS:lnter the tank capacity. For cornpartrnentalized tanks, enter data for the comparttnent covered by this tank foun only. 431. NUMBER OF COMPARTMENTS IN THE UNIT: If the tank is a compaftment, enter the total nutnber of comparttnents in the unit. 439. TANK USE - Check the type oftank usage. 439a. If you checked "Other" speciff the type of tank usage in the space provided. 440. TANK CONTENTS Check the specific petloleurn or non-petroleutn substance stored. 440a, Ifyouchecked..Otherpetroleutn"'specifuthecouunonnarneofthesubstanceinthespaceprovided[i.e.,thenameusedinthefacility'sHazardousMaterials Business Plan (HMBP) inventoryl. 440b. Ifyouchecked,'OtheriunderNon,petroleurn,specifothecornlnonnalneofsubstanceinthespaceprovided(i.e.,thenarneusedintheHMBPinventory). 443 . TYPE OF TANK - Check the box that identifies the type of tank. 444. TANK PRIMARY CONTAINMENT - Check the ionstruction material of the prirnary containment (i.e., inner tank wall nearest the hazardous substance stored). If the tank material is not listed, check "Other" and specift the rnaterial in the space provided. 444a. If you checked ,,othet'' specifu the type of prirnary contaimnent in the space provided. 445. TANK SECONDARy CbNTAINMSN1 - Check the construction rnaierial of the secondary contairunent that provides contairunent extemal to, and separate frorn, the prirnary containment described above. If the tank is a single-wall tank, check "None." If the rnaterial is not listed, check "Other" and specif, the rnatedal in the space provided (e.g., HDPE). 445a. lfyou checked "other" specifu the type ofsecondary containment in the space provided. 452 OVERFILL PREVENTION - Check the box(es) to describe the type(s) of overfill protection equipment installed. 45g. pIpING SYSTEM TypE - Check the type of producVwaste piping installed in this tank systern. "Safe suction" refers to piping systems rneeting all requirernents of23 CCR $2636(a)(3) (also-known as "European Suction" systerns) (i.e., sloped suction piping systems with no valves or pulnps below grzde and only one check vatve, located below and as close as pmctical to the suction purnp). Title 23, Califomia Code of Regulations is available online at www.calregs.cotn. 460. PIPING CONSTRUCTION-lndicate if the piping is single-walled or double-walled, or "other". 464. plplNc PRIMARY CONTAINMENT, Check the rnaterial(s) used to construct the prirnary (i.e., inner) underground producVwaste piping. 464a. If you checked ..other" specis the type of prirnary contairunent in the space provided. 464b. plpING SECONDARY CoNTAINMENT - Check the rnaterial(s) uied to construct the secondary contairunent systern(s) (i.e., secondary piping, trench) provided for the producVwaste piping. For single-wall piping systems, check "None." 464c. Ifyou checked "other" specifu the type ofsecondary contairunent in the space provided. 464d. PIPING/TURBINE CONhAINMENT SUMP TYPE Indicate the type of pipinlurbine contairunent surnp(s). check'None" if not present' 464e-el VENT PRIMARY CONTAINMENT Check the material(s) used to construct the prirnary (i.e., inner) vent piping. (Note: Address venting of the tank primary contairunent only.) Specifu Other type ofcontairunent in the space provided. 464f-fl VENT SECONDARY CoNTAINMENT - Check the rnaterial(s) used to construct the secondary containment systern(s) (e.g., secondary piping,) provided for the vent piping. For single-wall piping systerns, check "None." (Note: Ad<lress venting of the tank prirnary containment only.) Specify Other type of containment in the space provided. 4649-9lVR PRIMARY CONTAINMENT - Check the rnaterial(s) used to construct the prirnary (i.e., inner) vapor recovery piping. For tanks without vapor recovery piping(e.g.,Dieseltanks),check"None." SpecifoOthertypeofcontaintnentinthespaceprovided. 464h-hl vR sEcoNDARy CONTAINMENT - Check the rnateriai(s) used to construct the secondary containment systern(s) (e.g., secondary piping) provided fol the vapor recovery piping. For single-wall piping systems, check "None." Specifo Other type of containment in the space provided. 464i. VENT PIPING TRANSITION SUMP TYPE Indicate type of transition surnp(s). Check "None" if not present. 464j-j I RISER PRIMARY CONTAINMENT - Check the rnaterial(s) used to construct the prirnary (i.e., inner) piping for all risers (not drop tubes) other than annular spacerisers(i.e.,risersforfillingorgaugingoftheprirnarytank). SpeciffOthertypeofcontainmentinthespaceprovided. 464k-kl RISER SECONDARY CONTAINMENT - Checkihe mut".iullr; used to construct secondary containment systern(s) (i.e., secondary piping, surnps) provided for the riser piping. For risers without secondary contairunent, check 'None." Specifo Other type of containment in the space provided 45la-c. FILL COMPONENTS INSTALLED - Check the appropriaie boxes to show that spill contairunent, tank bottoln protection, and fill contairunent surnps (if applicable) are installed. 46ga. UDC CONSTRUCTION TypE - Check the box to describe the type of dispenser containrnent systern(s) (i.e., dispenser sumps or pans). If the systetn has no dispensers(e.g.,standbygenemtortanksystern),check"NoDispensets." Ifthesysternhasadispenser,butnoUDC,check"None". 46gb. UDC CONSTRUCTION MATERIAL - Check the box to describe the Inaterials used to consttuct the UDC. 469c. If you checked "Othet'' specifo the construction material in the space provided. 44g. STEEL COMp9NENT iROiECTIoN - All systerns contain sorne steel components. Check the appropriate box(es) to describe all conosion protection methods used. ..lsolation" means electrical isolation frorn soil, backfill, and groundwater. Examples include fiberglass cladding, non-rnetallic secondary contaimnent systerns which isolate steel components ftom the sub-sutface environment, and insulating bushings. APPLICANT SIGNATURE - The same person who signs the UST Operating Pennit Application - Facility Infonnation Fonn shall sign in the space provided. This signaturc ceftifies that the signei believes thaf all infonnation submitted is true and accumte, and that the UST system is cornpatible with the hazaldous substance stored. 470. DATE - Enter the date the fonn was signed. 471. APPLICANT NAME - Print or Rpe the narne of the person signing the fonn. 472. APPLICANT TITLE - Enter the title of the person signing the fonn. UPCF UST-B - 2/2 Rev. (12l2007) -.VNIFrED PROGRAM CONSOLIDATED FORy-..j UNonRGROUNDSTORAGETANK l MONITORING PLAN - (Paee I of 2) TYPEOF ACTION X I. NEW PI-NN E 2. CHANGE OF INFORMATION 490-l PLAN TYPE (Check one itern only) E 1. MONITORING IS IDENTICAL FOR ALL USTs AT THIS FACILITY 490-2 2. THIS PLAN COVERS ONLY THE FOLLOWING UST I. FACILITY INFORMATION 000048IFAFACILITY lD # (Agency Use Only) BUSINESS NAME (Sarne as FACILITY NAME) United Parcel Service 3. 104.CIrY San Luis ObisPoBUSINESS SITE ADDRESS 3601 SACTAMCNTO DT,103. II. EQUIPMENT TESTING AND PREVENTIVE MAINTENA}ICE etc.) must be perfonned at the fi'equency rnust be perfonned by qualified personnel. leaklineofprobes,sensors,(e.g.calibrationandrnaintenance, lnore and that worksuchrnanufacturerc'or whicheverinstructions,annually frequent,the equlpmentbyspecified 26412634CCR MONITORING EQUIPMENT IS SERVICED E t. etwuellv X gs. orHen (Specifu): Monthly PM perfonned 490-3a 490-3b III. MONITORING LOCATIONS ! T. T\NW SITE PLOT PLAN/MAP SUBMITTED WITH THIS PLAN. 8 2. SITE PLOT PLAN/MAP PREVIOUSLY SUBMITTED. (23 263414e0-4 ccR s2632, IV. TANK MONITORING IS PERFORMED USING THE FOLLOWING METHOD(S): X t. coNrtNuous ELEcTRoNIC TANK MoNIToRING oF ANNULAR 490-5 490-6 VAULT(S) WITH AUDIBLE AND VISUAL ALARMS. (23 CCR 52632,2634) SECONDARYCONTAINMENTIS: E A.DRY X t.T-IQUIOFILLED E C.PRESSURIZED Ad.UNDERVACUUM SPACE(S) OR SECONDARY CONTAINMENT(INTERSTITIAL) 490-8MoDEL#: TLS-350490-'1.PANEL MANUFACTURER: VEEdCT ROOI MoDEL #(s): VPt# 794390-302 490-1 0 LEAK SENSOR MANUFACTURER: VEEdET ROOI 490-9. 2. AUTOMATIC TANK GAUGING (ATG) SYSTEM USED TO MONITOR STNGLE WALL TANK(S). (23 CCR 52643) 490-11 il 490-13 490-15 490- PANEL MANUFACTURER: VEEdET ROOt IMODEL#(S):IN-TANK PROBE MANUFACTURER: VCCdET ROOt E c. WEEKLYE u. oeu-vTNIGHTLY E e.OTHER E c. OTHER (Specifu):X b.0.2 s.p.h 4eo't2 MoDEL #: TLS-350 LEAKTESTFREQUENCY: E A.CONTINUOUS X o. voNrur-Y PROGRAMMEDTESTS: E a.0.1g.P.h. fl :. vlonurr,y STATISTIcAL INVENToRY RECoNCILIATIoN (23 ccR 52646.r): 490-20 E +. wenrly MANUAL TANK GAUGING (MTG) (23 ccR S264s).TESTING PERIOD: ! A. 36 HOURS E t. OO HOURS 490-2], 490-22 5. TANK INTEGRITY TESTING (23 CCR $2643.1): TEST FREQUENCY: E a. ANNUALLY N b. BIENNIALLY E C. OTHER (SPECifY): 490-23 490-24 490-25 U E gs. orHEn (specifu): 490-26 490-27 V. PIPE MONITORING IS PERFORMED USING THE F'OLLOWING METHOD (Check all that PANEL MANUFACTURER: VEEdET ROOI 490-30 LEAK SENSOR MANUFACTURER: VEEdCT ROOt 490-32 OF PIPE/ PIPING SUMP(S) AND OTHER SECONDARY CONTAINMENT WITH vrsuAl. ALARMS. (23 CCR S2636) SECONDARY CONTAINMENT IS: 8A. DRY Eb. LIQUID FILLED EC. PRESSURIZED EA. UNOEN VACUUM 490-29 490-3t 490-33 490-34 490-35 PIPING LEAK ALARM TRIGGERS AUTOMATIC PUMP (i.e., TURBINE) SHUTDOWN. FAILURE/DISCoNNECTION oF THE MoNITORING SYSTEM TRIGGERS AUTOMATIC PUMP SHUTDOWN. E a. YES E U. NO MODEL vI(#794380-205 AUDIBLE AND MoDEL#: TLS-350 Ea.YES !b.No I. CONTINUOUS p.h. LEAK TESTS AND RESTRICTS OR SHUTS OFF2. MECHANICAL LINE LEAK DETECTOR (MLLD)THAT ROUTINELY PERFORMS 3.0 g' PRODUCT FLOW WHEN A LEAK IS DETECTED ccR MLLD Red Jacket 490-36 490-384eo-3'7 MoDEL#(s): FX1D D 3, ELECTRONIC LINE LEAK DETECTOR (ELLD)THAT ROUTINELY PERFORMS 3.0 g.p.h. LEAK TESTS (23 CCR S2636)490-39 MODEL ):ELLD MANUFACTURER(S) 490-40. PROGRAMMED IN LINE LEAK TEST: I I. UWNAUM MONTHLY 0.2 g.P.h, ELLD DETECTION OF A PIPING LEAK TRIGGERS AUTOMATIC PUMP SHUTDOWN ELLD FAILURE/DISCONNECTION TRIGGERS AUTOMATIC PUMP SHUTDOWN. E 2. MINIMUM ANNUALo.I g.p.h. [] a.YES nt.uo !a.YES nr.No 490-43 490-44 5. VISUAL PIPE MONITORING. FREQUENCY ! A. DAILY E b. WEEKLY * Allorved for tuel HSC 4. PIPE INTEGRITY TESTING 490-45 TEST a- ANNUALLY 490-46 490-47 E c. MIN. MONTHLY & EACH TIME SYSTEM OPERATED* b. EVERY 3 YEARS c. OTHER 490-48 490-49 n e . sucrloN pIpING MEETS EXEMPTION CRITERIA [23 ccR $2636(a)(3)1.490-50 I z. NO REGULATED PIPING PER HEALTH AND SAFETY CODE' DIVISION CHAPTER 6.7 IS CONNECTED TO THE TANK SYSTEM 490-5 | 20, n 99. OTHER (specifu) 490-52 490-53 uPcF usr-D (1212007) l/4 ,) UST Monitoring Plan - Page I Instructions Complete a separate UST Monitoring plan for each UST monitoring system at the facility. This form must be submitted with your initial UST Operating Permit Application and within 30 days of changes in the information it contains. Please note that your local agency may require you to obtain approval prior to installing or -oiifying monitoring equipment. (Note: Numbering of these instructions follows the data element numbers on the form') 490-1. TYPE OF ACTION - Check the appropriate box to indicate why this plan is being submitted. 490-2. PLAN TypE - Check the app.op.iui" bo* to indicate whether this plan covers all, or rnerely some, of the USTs at the facility. If the plan covets only some of the tanks, identify those tanks in the space provided [e.g., by using the Tank iO *1r; in item 432 ofthe UST Operating Pennit Application - Tank Information Fonn(s)]' l. FACILITY ID NUMBER - This space is for agency use only. 3. BUSINESS NAME - Enter the complete Facility Name. I 03, BUSINESS SITE ADDRESS - Enter the street address where the facility is located, including building nurnber, ifapplicable. Post offce box numbers are not acceptable This infonnation tnust provide a means to locate the facility geographically. I 04. CITY - Enter the city or unincorporated area in which the facility is located. 490-3a MONITORING EQUIPMENT IS SERVICED - Check the appropriate box to speciry the frequency of monitoring equipment testing/certification. 490-3b Specify Other frequency for monitoring equiptnent servicing control panel, etc.). 490-5 IV-l CONTINUOUS ELECTRONIC MONITORING-Indicate if this rnonitoring method is being used to monitor the tanks. 490-6 SECONDARY CONTAINMENT- If IV- l is checked, check the appropriate box to describe the enviromnent inside the tank secondary containment 490-7 PANEL MANUFACTURER - If IV- I is checked, enter the name of the manufacturer of the monitoring system control panel (console). 490-8 MODEL # - If IV-1 is checked, enter the model number for the monitoring system control panel. 490-9 LEAK SENSOR MANUFACTURER - If IV- 1 is checked, enter the narne of the rnanufacturer of the sensor(s). If additional space is needed, use Section X. 490- I 0 MODEL #(S) - If IV- I is checked, enter the model number for each type of sensor installed. If additional space is needed, use Section X. 490-ll IV-2 AUTOMATIC TANK GAUGING-Indicate if this rnethod is used for rnonitoring the UST's. 490-12 PANEL MANUFACTURER - If IV-2 is checked, enter the name of the manufacturer of the monitoring system control panel (console). 490-13 MODEL # - lf IV-2 is checked, enter the model nurnber for the monitoring system control panel. 490-14 IN-TANK PROBE MANUFACTURER If IV-2 is checked, enter the name of the manufacturer of the probe(s). 490- I 5 MODEL #(S) - If IV-2 is checked, enter the model number for each type of in-tank probe installed. If additional space is needed, use Section X. 490-l 6. LEAK TEST FREQUENCY - If IV-2 is checked, check the appropriate box to describe the in-tank leak test frequency. 490-1 7. SPECIFY - If490-l 6e is checked, enter the frequency ofprogramtned leak tests. 490-18. PROGRAMMED TESTS - If IV-2 is checked, check the appropriate box to describe the tests programmed into the ATG systern. 490-19. SPECIFY - If 490-l8c is checked, entsr the frequency ofin-tank leak testing. 490-20.tV-3INVENTORYRECONCILIATION-Checktheboxifstatistical inventoryreconciliationisperfonned. 490-21 . IV-4 WEEKLY MANUAL TANK GAUGING. Indicate if this method is used to monitor the tanks. 490-22. TESTING PERIOD - If IV-4 is checked, check the appropriate box to describe the MTG testing period. 490-23.tV-5 TANK INTEGRITY TESTING: Indicate if this method is used to monitor the tanks. 490-24. TEST FREQUENCY If IV-5 is checked, check the appropriate box to describe the frequency of tank integrity testing. 490-25. OTHER: If 490-24c is checked, speciry other test frequency. 490-26.IV-99 OTHER: Indicate if rnonitoring of the tanks occurs that is not indicated in any other category. 23CCR 92648). Include the rnonitoring frequency (e.g., Continuous, Weekly). If additional space is needed, use Section X. 490-28. V-l coNTTNUoUS M9NTT6RTNG oF prpE/plpiltil SUMP(S) AND tjTHER SECONDARY CONTAINMENT wlTH AUDIB LE AND VISIJAL ALARMS: Indicate if this is the monitoring rnethod used for the piping 490-29. SECONDARY CONTAINMENT: If V-l is checked, Check the appropriate box to describe the environment inside piping secondary containment. 490-30.PANELMANUFACTURER IfV-lischecked,enterthenarneofthemanufacturerofthernonitoringsystemcontrolpanel(console). 490-3 I . MODEL # - If V- I is checked, enter the rnodel number for the monitoring system control panel. 490-32. LEAK SENSOR MANUFACTURER - If V-l is checked, enter the narne of the manufacturer of the sensor(s) 490-33. MODEL #(S) - IfV-l is checked, enter the nodel nurnber for each type ofsensor installed. Ifadditional space is needed, use Section X' 490-34. PIPING LEAK ALARM T RIGGERS AUTOMATIC PUMP SHUTDOWN _ If V-l is chECKCd, ChECK YES OT NO. 490-35. FAILURE/DISCONNECTION OF THE MONITORING SYSTEM TzuGGERS AUTOMATIC PUMP SHUTDOWN _ If V-1 iS ChCCKEd, ChECK YES OT NO. 490-36. V-2 plpE MECHANTCAL LINE LEAK DETECTORS PERFORM 3 GPH LEAK TESTS: Indicate if this rnonitoring method is used to rnonitor the pipelines. 490-37.MLLD MANUFACTURER(S) If V-2 is checked, enter the narne(s) of the manufacturer(s) of the mechanical line leak detector(s). If additional space is needed, use Section X. 490-3g. MODEL #(s) - IfV-2 is checked, Enter the model nurnber for each type ofmechanical line leak detector installed. Ifadditional space is needed, use Section X. 4g0-3g.V-3 pIpE ELECTRONIC LINE LEAK DETECTORS: Indicate if this rnonitoring rnethod is used to monitor the pipelines. 490-40. ELLD MANUFACTURER - If V-3 is checked, Enter the name of the manufacturer of the electronic line leak detector(s). 490-4 I . MODEL #(S)n - If V-3 is checked, enter the model nurnber for each type of electronic line leak detector installed. If additional space is needed, use Section X. 4g0-42. PROGRAMMED LINE INTEGRITY TESTS -lf V-3 is checked, check the appropriate box to describe the type of tests programmed into the rnonitoring system. 490-43, ELLD DETECTION OF A PIPING LEAK ALARM TRIGGERS PUMP SHUTDOWN - If V.I iS ChCCKEd, ChECK YCS OT NO. 4gO-44.ELLD DETECTION OF A PIPING LEAK FAILURE/DISCONNECTION TRIGGERS PUMP SHUTDOWN. _ If V-l iS ChECKEd, ChECK YES OT NO. 490-45.V-4 PIPE INTEGRITY TESTING - Indicate if this monitoring method is used to rnonitor the pipelines. 490-46. TEST FREQUENCY - If V-4 is checked, check the appropriate box to describe the frequency of pipe integrity testing. 490-47. SPECIFY lf 490-46-99 is checked, enter the frequency ofpipe integrity testing. 490-48.V-5 VISUAL PIPE MONITORING - Indicate if this rnonitoring rnethod is used to rnonitor the pipelines. 490-49. lfV-s is checked, check the appropriate box to describe the flequency of visual rnonitoring. 490-50. SUCTION PIPING MEETS EXEMPTION CRITERIA - Indicate if this rnonitoring rnethod is used to rnonitor the pipelines. 490-5 I . No REGULATED ptpING pER HEALTH AND SAFETY coDE, DIVISION 20; CHAPTER 6.7 IS CONNECTED To THE TANK SYSTEM - check this box if no piping in the tank systern is regulated under the UST law, or there is no piping. 490-52.V-99 OTHER - Indicate if another method is used for pipeline monitoring. 490-53.SpECIFy-Enterabriefdescdptionoftheotherlineinonitoringmethod(s)used. Ifadditionalspaceisneeded,seeSectionX. Besuretoclearlydescribe rnonitoring rnethod(s) and frequency. Materials Business Plan rnap, etc.) that shows all required infonnation, include it with this plan. uPcF usr-D (12/2007) 2/4 . INIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK MONITORING PLAN (Page2of 2) VI. UNDER DISPENSER CONTAINMENT (UD MONITORING PANEL MANUFACTURER: Veeder Root 490-55 1. UDC MONITORING IS PERFORMED USING THE FOLLOWING METHOD n r. coNrrNuous ELECTRoNTc MoNrroRrNG n z. ploer AND cHAIN ASSEMBLY I :. r.lecrnoNlc srAND-ALoNE 490-54b MODEL#: TLS - 350 MODEL#(S): 33012-001 490-56. 490-58 E + No DTsPENSERS n ss. ornen 490-5'7LEAK SENSOR MANUFACTURER:Veeder Root DETECTION OF A LEAK INTO THE UDC TRIGGERS AUD]BLE AND VISUAL ALARMS UDC LEAK ALARM TRIGGERS AUTOMATIC PUMP SHUTDOWN FAILURE/ DISCONNECTION OF UDC MONITORING SYSTEM TRIGGERS AUTOMATIC PUMP SHUTDOWN. E a. YES X a. YES X a. YES E a. YES Xb.No Eb.No fl b. No Eu.No 490-59 490-60. 490-61 490-62UDC MONITORING STOPS THE FLOW OF PRODUCT AT THE DISPENSER. 2. UDC CONSTRUCTION IS 8I. SINGLE-WALLED ! Z. OOUSLE-WALLED 490-63 A LEAK WITHIN THE SECONDARY CONTAINMENT OF THE UDC TRIGGERS AUDIBLE AND VISUAL ALARMS IF DOUBLE WALLED: !a.YES !b.No E 2. PRESSURE 3. VACUUMUDC INTERSTITIAL SPACE IS MONITORED BY: VII. PERIODIC SYSTEM TESTING ELD TESTING: THIS FACILITY HAS BEEN NOTIFIED BY THE STA LEAK DETECTION (ELD) MUST BE PERFORMED, PERIODIC ELD IS P TE WATER RESOURCES ERFORMED EVERY 36 MONTHS AS REOUIRED. (23 CCR $2644.I) BOARD THAT ENHANCED 4e0-65. 2, SECONDARY CONTAINMENT COMPONENTS ARE TESTED EVERY 36 MONTHS,x 490-66 490-6'1 VIII. RECORDKEEPING 3. SPILL BUCKETS ARE TESTED ANNUALLY The following rnonitoring/maintenance records are kept for this facility: [l Alann logs .tso-osu X Visual Inspection Records +qo-esu ! SIR testing results (and supporting documentation records). +eo-osa ! a.fC Testing results (and supporting docutnentation recotds). alo-ett I Equiprnent mair.rtenance and calibration recotds. 490-68h Tank integrity testing results 490-68c Tank gauging results (and supporting documentation records). leo-es" Conosion Ptotection 60-day logs .oo-oeg xn IX. TRAINING X persolnel with UST rnonitodng responsibilities are familiar with all of the following documents relevant to their job duties +qo-oqa REFERENCE DOCUMENTS MAINTAINED AT FACILITY (Check all that applv) THIS UNDERGROUND STORAGE TANK MONITORING PLAN (Required) aro-oeu OPERATING MANUALS FOR ELECTRONIC MONITORING EQUIPMENT (Requifed) reo-olc El cALIFoRNtA UNDERGRoUND sroRAGE TANK REGULATIoNS 4e0-6ed E CALIFoRNIA UNDERGROUND sroRAcE TANK LAW +so-oce ! srere WATER RESOURCES CONTROL BOARD (SWRCB) PUBLICATION: "HANDBOOK FOR TANK OWNERS STATISTICAL INVENTORY RECONC ILIATION'' 490.69I n swRCB PUBLICATION: ,'UNDERSTANDING AUTOMATIC TANK GAUGING SYSTEMS" +so-ese ! orunn lspecifu): nao*, vosi - MANUAL AND training will include, but is not lirnited to, the following: F Operation of the UST systems in a rnanner consistent with the facility's best managetnent pmctices F The facility ernployee's role with regard to the rnonitoring equipment as specified in this UST Monitoring Plan F The facility ernployee's role with regard to spills and overfills as specified in the UST Response Plan ) Narnes ofcontact person(s) for ernergencies and tnonitoling alanns. +so-lo lntemational Code Council (ICC).the California UST Systern Operator Exam adtninisteredThis facility has a "Designated UST who has passed and within 30 days ofhire. Thisproper opelation and tnaintenance ofthe UST systetns annually,The "Designated UST Operator" will train facility ernployees in the are attached to this plan. +so-zlProvide additional comtnents or X. COMMENTS/ADDITIONAL INFORMATION how many pages with on specific tnonitoring XI. PERSONNEL RESPONSIBILITIES detection coveredrnaintenanceandUSTofleak bydaitheUSTactivitiesequiprnent1Sforthat:rnonitoringUSTTheensuflng)lylroutineOwner/Operator responsible rnaintainedandallarerecordsaindicatereleasemonitoring properly.aleconditionsallthat investigated,3)this 2)possibleoccul's,plan and maintenance:afe for theThe rnonitoring equiprnentfollowingpelson(s)responsible perfonning 73490-ServiceIsland ContractorTITLE490-72 FuelServiceB&T StationNAME 490-'/54eo-74 TITLENAME CERTIFICATION the facility, provide a repofi to the owne/opetator, and infonn the owner'/opetator of anyThe Designated Opemtor perfonn a rnonthly visual conditions lhat need lollow-up action. OWNER/OPERATOR SIGNATURE herein is true and accurate to the best ofrn 490-'76APPLICANT SIGN 1- lA- drll DATE:490-'t7 APPLICANT TITLE President 490-'19 APPLICANTNAME (print) Noel Massie 490-78/ UPCF UST-D (12/2007) 3 /4 (Agency Llse Only) This plan has been reviewe- 'd:! Approved fl Approved With Cond"'-ns local Agency Signature: Comments or Special Conditions: UST Monitoring Plan - Page2Instructions Cornplete a separate UST Monitoring Plan for each UST rnonitoring system at the facility. This fonn must be subrnitted with your initial UST Operating pennit Application and wiihin 30 days of changes in the infonnation it contains. Please note that your local agency may require you to obtuin up-p.o,rul prioi-to installing or rnodiSing rnonitoring equiprnent. (Note: Nurnbering of these instructions follows the data eletnent nutnbers on the fonn.) 490-54a. MONITORING OF THE UNDER DISPENSER CONTAINMENT- Indicate the method used for UDC monitoring. 490-54b. SPECIFY-lf 99 "Other" is checked, describe other method used. IfVI-l -1, VI-l -2 or VI-1 -3 or VI-l -99 is checked, cornplete 490-55 to 490-64b 490-55. PANELMANUFACTURER Enterthenarneoftherninufacturerofthemonitoringsystemconttolpanel(console). Ifthereisnocontrolpanel(e.g.,onlyanelectrical relay box is installed) leave this space blank. this space blank. 490-57. LEAK SENSOR MANUFACTURER - Enter the name of the manufacturel of the sensor(s). 490-58. MODEL #(S) Enter the rnodel nurnber ofthe sensor(s) installed. Ifadditional space is needed, use Section X. 490-59. DETECTION OF A LEAK INTO THE UDC TRIGGERS AUDIBLE AND VISUAL ALARMS. INdiCAtC YES OT NO 490-60. UDC LEAK ALARM TRIGGERS PUMP SHUTDOWN - Indicate Yes or No 490-6I . FAILURE/DISCONNECTION OF UDC MONITORING SYSTEM TRIGGERS AUTOMATIC PUMP SHUTDOWN - INdiCAtE YES OT NO 490-62. UDC, MONITORING STOPS THE FLOW OF PRODUCT AT THE DISPENSER. Indicate YES OT NO. 490-63. UDC CONSTRUCTION - Indicate if the construction of the UDC is single-walled, or double-walled. 490-64a. DOUBLE-WALLED INTERSTITIAL SPACE MONITORING - Indicate rvhat is used to rnonitor the interstitial space. 490-64b. LEAK WITHIN THE SECONDARY CONTAIMENT OF UDC TRIGGERS AUDIBLE AND VISUAL ALARMS - INdiCAtE YES OT NO 490-65. VII- I ELD TESTING - Check the box if you have been notified by the State water Resources Control Board (SWRCB) that the UST(s) covered by this plan is/are subject to Enhanced Leak Detection Requirements (i.e., UST has any single-wall component and is located within 1,000 feet ofa public drinking water well). 490-66. TESTING OF SECONDARY CONTAINMENT COMPONENTS EVERY 36 MONTHS - Check the box if you have secondary containment that requires testing. 490-67. SPILL BUCKET TESTING - Check the box ifyou have spill buckets. 490-68a-h. VIII RECORDKEEPING lndicate which rnonitoring and equipment maintenance records are maintained for this facility. 490-69a IX TRAINING STATEMENT - Check the box to veriry that the statement is true. REFERENCE DOCUMENTS MAINTAINED AT FAaILITY - Check the appropriate boxes to describe reference docurnents rnaintained at the facility. Note that the first two items on the list rnust be kept at the facility. 490-69b. MONITORING PLAN: lndicate that this plan is kept as a reference document. 490-69c.. OPERATING MANUALS FOR ELECTRONIC EQUIPMENT: Indicate that this plan is kept as a reference document. 490-69d. CA UST REGULATIONS - Indicate that this is kept as a reference document 490-69e, CA UST LAW - Indicate that this is kept as a reference docutnent. 490-69f. STATE WATER RESOURCES CONTROL BOARD (SWRCB) PUBLICATION - "HANDBOOK FOR TANK OWNERS - MANUAL AND STATISTICAL INVENTORY RECONCILIATION - Indicate that this is kept as a reference docutnent. 490-699. SWRCB PUBLICATION: ,,LINDERSTANDING AUTOMATIC TANK GAUGING SYSTEMS": Indicate that this is kept as a reference document. 490-69h. OTHER - Indicate that other reference documents are kept. 4g0-6gi. spECIFy-lf,,OTHER" is checked, enter a briefdescription ofthe other document(s) rnaintained at the facility. Ifadditional space is needed, see Section X. 490-70. DESIGNATED OPERATOR TRAINING - Check this box to verifu that this staternent is true. 4g0-71. coMMENTS/ADDITIONALINFORMATION-Makeadditionalcomrnentsoryoumayattachandidentiffthenurnberofadditionalpagesofinfonnationtodescribe any additional UST system monitoring-related infonnation (e.g., additional infonnation required by your local agency). Attach any monitoring logs that you will be using for the rnonitoring ofyour tank systern. 490-72. NAME Enter the narne of the person who routinely conducts the monitoring and equipment maintenance under this plan. 490-73. TITLE - Enter the title of the person. 490-74. NAME - Enter the name of thl second person, if applicable, who routinely conducts the monitoring and equiprnent maintenance under this plan. 490-7 5. Tl'lLE - Enter the title of the second person. owNER/OPERATOR SIGNATURE - The tank owner/operator, facility owner/operator, or an authorized representative of the owner shall sign in the space provided. This signature certifies that the signer believes that all infonnation subrnitted is true, accurate, and cornplete, and that the training progratn specifed in Section IX has been irnplernented. 490-76. REPRESENTING - Check the appropriate box to indicate whether the signer is the UST owner/operator, the UST facility owner/operator, or an authorized representativg of the owner. 490-77 . DATE - Enter the date the plan was signed. 490-78. APPLICANT NAME - Print or type the narne of the person signing the plan. 490-79. APPLICANT TITLE Enter the title of the person signing the plan. UPCF UST-D (12/2007) 4/4