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HomeMy WebLinkAboutSLOUNIFLOW_FS1 Admin iRC3926i Color_0173_001_RedactedUN WIED PROGRAM CONSOLIDATED FORM FACU.ITY INFORMATION RiTCTW..SS ACTIVITIES page 1 of 1. FACILITY IDENTIFICATION FACILITYIOa I EPA IDY(Hamrdom Wasc Only) t F A 0 0 0 4 8 1 0 cAD9E1604022 (Agenry Usc Only) s BUSINESS NAME(Stanom many New ofDBA-Doing UMMS As) VIN IT BUSINESS SITE ADDRESS 3601 SAGRAMLNTO DR no 101 I I 93 0i'a Busmsssinc3TY SAN LUIS OBISPO CA ZIP CODE D. ACTIVITIES DECLARATION NOTE: If you check YES to any part of this list, plastic submit the Business Owner/O xnrator Identification Does Your facility... it yak phase complete these pages of the UPCF.... A. HAZARDOUS MATERIALS Have on site (for any purpose) at any one time, hazardous materials at or above HAZARDOUS MATERIALS 55 gallons for liquids, 500 pounds for solids. or 200 cubic Ra for compressed © YES INVENTORY —CHEMICAL graves (include liquids in ASfs and USTs)I or the applicable Federal threshold DESCRIPTION quantity for an extremely hazardous substance specified in 40 CFR Part 355, Appendix A or B; or handle radiological materials in quantities for which an ems enc en is uired m rsutto 10 CFR Puts 30. 40 or 707 B. REGULATED SUBSTANCES Have Regulated Substances stated trundle in quantities greater than the El VIES Cmedinak wire yoarlocd egenay threshold quandtes established by the California Accidemil Release respmnible for CNARP. prevention Program (CaIAPI pr IINDERGRZO STORAGE TANKS (USTs) UST FACILITY maamyaWR1!8"A) Own or operate underground storage tanks? UST TANK (anteater mt) mummy fee, B) D. ABOVE GROUND PETROLBUMSTQRAGE Own or opereh ASTs above time thresholds: Stare greater than 1.320 gallons ofparelmm products (new or used)in AYES NO FORM REQUIRFDTOCUPAS abovegrouM ranks or constants. E. HAZARDOUS WASTE Generate hazardous waste? AYES Epp IDNUMBER— oriel¢ azlhc kP of P mispege Recycle more than 100 kg/month of excluded or exempted recyclable AYES RECYCLABLE MATERIALS REPORT materials (per H&C 25143.2)? ta.Pertcycbl Treat hazardous waste on -site? - AYES ON -SITE HAZARDOUS WASTE TREATMENT —FACILITY ONSITE HAZARDOUS WASTE TREATMENT —UNIT taeimeweno Treatment subjeello financial assurance requirements(for permit by Rule and CERWICATION OF FINANCIAL Conditional Authorization)? ❑YES ASSURANCE Consolidate hazardous waste generated al a remote site? YES REMOTE WASTE CONSOLIDATION SITE ANNUAL NOTIFICATION Need to report theclosure/ranoval of a tank that was classi0ed as AYES HAZARDOUSWASTETANK hazardous waste and cleaned on -site? CLOSURE CERTIFICATION Generate in any single calendar month 1,000 kilograms (kg) (2,200 pounds) or Obtain federal EPA ID Number, file more of federal RCRA hazardous waste, or generate in any single calendar ❑ YES Biennial Report (EPA Form 8700- month, or accumulate at any time, I kg (2.2 pounds) of RCKA acute hazardous 13AMI and satisfy requirement for walk; or generate or accumulate at any time more than 100 kg(220 pounds)of RCRA Large Quantity Oenuator. spill cleanup materials contaminated with RCRA acme hazardous waste. Household Hazardous Waste(H1IW) Collection Sim? AYES See CUPA for required fanre. v Is F. LOCAL REQUIREMENTS (You may aim he mquimdro Prov deaddikhel Flamuim by yourMPAorIaod ¢Panay.) e Feb.(1Ps2007) UNIFIED PROGRAM CONSOLD)ATEO FORM — FACILITY INFORMATION S OWNER/OPERATOR IDENTIFICATION I_ IDENTIFICATION CA II_BVSINESS OWNER DI. ENVIRONMENTAL CONTACT -PRUdARY- IV, EMERGENCY CONTACTS ,n SECONDARY. ADDITIONAL LOCALLY COLI.WM LMFORMATION: am hlmlliir wish UNIFIED PROGRAM CON50yD) UNDERGROUNDSTORAGE TgNKORM OPERATING PERMIT APPLICATION— FACILITY INFORMATION TYPE pFACTION ❑ I. NEW PERMIT ❑ APPLICATION OF IN (One form (CM1ev>s eneilomamlrl ®3. RENEWAL PERMIT FORMATION ❑ 6.TEMPORgRY FpCILITV CLOSURE E3 TRANSFER PERMIT CLOSURE ❑ 9.TMNSFER PERMIT TDTAL NUMB ER OF USTS AT FACILITY a• FACIT,TTY BYFORMATION ( FAC)LITYMI FACILITY TYPE ID I.MOTOR VEHICLE FUELING San Lui10bi9 —� J F RM ❑ a PRnrcSSpR QMER 2.FUEL DISTRIBUTION � f71 kd 1 d II PROPERTYOWNER BVF �Y ®N paoPeRTY OWNER Nnnde ORMATION BT-OK LLC .m ...... M. IV. TANK OWNER TYPE: CA -- �., wue ❑ 4. LOCAL AGENCY/DISTRICT 93728 uv ❑ I. FEDERAL AGENCY 4COUNTYAGENCY ®8 NON GOVERNMENT ❑ 6 STATE AGENCY V BOARD OF EQUALIZATION UST STO TY KJ R 44_ D 7 2 2 9 4 RAGE FEE ACCOUNT NUMBER Call dm SprcB M fEgenlmrnppm.F IT D(Ii VI PERMIT HOLDER INFO f M1 q lerve Permit and send kgnl no[ihadons and mailimmpj b: RMATION ❑ I. FACILITY OWNER ❑ e, TANK OPERATOR al ® SUPERVISOR OF D}VIgION3. TANK OWNER ,SECTION, pR OFFICE (Required For Pubmk \\ A ❑S, FACIWTYOPERATOR M gexia Only) UPCF UST -A Rev. (122007) ) UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION -TANK INFORMATION (ogle Mrm IRFUS ) TYPE OF ACTgN (Chats ow item Only. For an UST Permanent closure or mmonaw. IrI: MWMismOSonmd3eGi0ns I, ILIILIV,NM U(below) ^m ❑ I. NEW PERMIT ® 3. RENEWAL PERMIT ❑ 5. CHANGE OF INFORMATION ❑ O.TEMPO&ARYUSTCLOSURE T, UST PERMANENTCLOSURE ONSITE ❑&LIST REMOVAL DATE UST PERMANENTLY CLOSED: DATE EXISTING UST DISCOVERED: 1. FACILITY INFORMATION FACILITY 10A (Ag y Um 01169 4 8 1 0 BUSINESS NAME (Same as FACRRYNAME ar DBA-DcinR Bvsirress AS) United Perce) Service Inn. EmOhLoCorpOretion , as CITY BUSINESS SITE ADDRESS UT Luis Obispo San 3601 Sacramento Drive IL TANK DESCRIPTION a' TANK MAMIPACfURBR xx TANKCONFIWMTIom THISTANKIS O° TANK ID N 01 ®1. A sTArvo-AIANETANK Owen Corning []j.ONE MACOM9ARTM¢MEN to. 05 TANK CAPACITY IN GALLONS ^� NUMBER OFCOMPARTMENTS INTHE llI41T °T' DATE SYSTEM INSTALLED DATE N/A OB/15/1989 1989 12000 IR.TANH USE AND CONTENTS ❑ 5EMEATIONFl1ENER ❑ IL.MARINOUS GFNCY GENERAtOR FUELINSO FxsxtlN.)1 TANK USE iB I,C ❑21 MICALFROLENBWNG WAG p S. CHEMICAL PROOUCFSTORAOE ❑ 4.HNKNMIU9 WA,lE O,eloxe Waon or ❑ 99.OFFIFR ❑ b, OTNEt GENERATge FUEL ❑ 95.UNKFfnWN ❑ L. REGULAR IJNLEADW ❑ Ic,MIDGRADEIINLEADED ❑ Ib. PREMIUMITNLEAOEO CONTENTS PETROLEUM: ® ,.DIESEL ❑ 5. JET FUEL ❑ 6.AVMTIONGAS Axon [)& PETROLEUM BLEND FUEL 139. NANOLROLEUM NON-PEIROIBUM:❑ ]. USW OIL um ❑ 11. OTNERNON-PEI'ROIEUM IV. TANK CONSTRUCTION 0 TVPEOFTANX ❑ 1. SINGLE WALL ®L.OWBL£WALL 93. UNKNOWN 4N FRIMARY COMAINhftM ❑ I. STEEL 09 ].FIBERGLASS 6. INFERNAL OLAOOER awe ❑ T. STSELi MTERNAL IRIINO ❑95.UNKNDwN ❑,,.OTHER (Seed( Mf SECONDARYCONTAINNIDNT ❑I. STEEL ®S.PIBERGLASS b.S%TERIOR MEMOR...... R pT. JACKETED aas ❑ 90. NONE ❑ piUWNOWN 199. OTHER(S t): 45a LA IBLEk VISUAL AL ARM, YI4MLYLOAT 3. FID.NNESINT-0PF VALVE OVERFILLPRLVENTION ❑ d. TANK MEETS REQUIREMENT6 FOR ENEMPITON FROM OVERFILLPREVENTION CQUIPMEN'r V. PRODUCT / WASTE PIPING CONSTRUCTION Am PNING consIFUCTTON ❑I. SINGLE -WALLED 2.DOUBIE.WAL4E0 ❑99. 0-' ne S.GMVITY 3.LONVENnONAL CnON 4, SAFESUCTION Z)MR •n aR SYSTEM TYPE ®1. PIlE&411RE CIA MWARYCONTAR1EM O I. STEEL 4. FIBERGLASS S. FLEXIBLE IO. RIGIDI'LASTIC AAWe p 5, NONE ❑ 95. UNKNOWN ❑ 99.OTHLRtspooly): Ne 10. AIOIDPLASTIC SECONDARY COST 90. NoL 95. UNRGLASS p99.cTHIIUL 90. NONE ❑ 9f. UNKNOWN ❑ ,,.OTHER ISYNN ,nN PIPINGA'U0.HINSCONJAINM@ITSUNITTYP6 M I. SINGLEWA'- 2. DOWLe WALL 9p.ONR old ' VENT, VAPOR RECOVERY ryR) AND RISER /FILL PIPE PIPING CONSTRUCTION AF VI. Fax VENT PRIMARYCOMA FLAT I. STEEL 4. n8[RGLA„ 10, RLOID PLASTIC ,,.NONE. ,,.OTHER (SpmN➢) ^ °W -0-1. EL A, FIBFAULASS IB.M1IOID PLASTIC 90. NONe 99. OTHER (9pslFy) ,NR VENTSECONDARYCOMAIWIFT Ne VR PRIINARY CONTAINM1IEM ❑ I. STEELd. FIBFR04lSS I4 Rt01O PLASTC 9p.NONE 99.OTImR(SP^ely) 4 1 I. Sliid A. FIBERGLASS 10. RIOIOPLASITC 90. NONE 99. OFI=FROMM °^1° VR SECONDARY CONTPINMENT ^Msl VENT RPMAILYCO1TI0N TYPE I. INGLE WPLL ❑1.DOUBLE WMG. 90.N01@ «u 10. RIOIDPLASTIC 90.NONE 99.4Yr11ER (Spew%) RISER PRM/ARV CUNTAMMGNT I. STEEL 4. FlBERGLA 4 1 ENT Ne RISMSECONDARYCONTAINKONi I. SIEd 4.FMEROLA33 10. RIGro PLASTC W.Nat E 99.OTHERI,pe9lfyJ 460I 9. AINMhNF, vise FILLCOVIPOMTSMSTALI FD ®I. SPILL BUCK 3.PENSRRCNOTAINM CONTAINMENT VR. UNDER DISPENSER CONTAINMENT (UDC) � CON9TRUCTIONTYPE 11 SINGLE WALL WALL ❑ 2. OOUBLG WALL &NODISPENSERS ❑ 90.101ONE ^ MATER li"' Q 4.FME0.GLA39 IOI RIGIUI'WSTIC ❑99, GTIPAL(9. i CONSTRUCTION VIIL CORROS[ON PROTECTION ..... .. .......: a. STEEL COR11C1NENT➢ ❑ l.SACRIPICIAL ANODE(S1 ❑ 9. PAPRGS3EOCURRENi ❑ b.ISOLAT[ON 1X. APPLICANT SIGNATURE H the STSY31 BCompatible with Me hazallowspUMna scored end that the intormatien provided 11"An is me, ememm, CERTIFICATION: I end' 1 0 In ne M 1 I AI al"menn. „y APPLICANTSIONA'RIR�Ii DATE( -a/. /)��� ne 1TI' APPLICAMTITLEII President APPLICANTNAME(print) I esSiE Rev.(ISI000.0 UPCFUST-B-1/1 UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK MONITORING PLAN —(Pap 102) TYPE OF AMON ❑ L NEW PLAN ® 2. CHANGE OF INFORMATION ° PLANTYPE ® LMONITORMG IS IDENTICAL FOR AILUSICATTHIS FACEJTY. ° Chock one item and ❑ 2. THIS PLAN COVERS ONLY THEFOLLOWING UST SYSTEMS 1. FACILITY INFORMATION FACILITY ID I(Arnq On Only) — 0 0 0— 4 8 1 0 ' BUSINESS NAME (Same as FACILITY NAME) United Parcel Swice Inc., an Ohio Ci rporatiOn L BUSINESS Sm AODREsa 3601 Swramento Drive CITY San Luis Obispo 10A 111 EQUIPMENT TESTING AND PREVENTIVE MAINTENANCE TAtin& ovgNive Tainte:wt Md aliWation of monimrNg equipment kc*. umov. prober, lino ]eek (IMCCIare, 00 most be Performed AMC MXIM003F spedGed by to equip:neN maoufamom% insHuctions, or annually, whichever is mom frequent, and that such wmk must be performed by qualified pemannel, s23 CCR 2I63Z,16]426]42641) MONITORING EQUIPMENT IS SERVICED ® I. ANNUALLY ❑ W. OTHER (SPerily): 490 s IIL MONITORING LOCATIONS 1. NEW -SITE PLOT PLAN/MAP SUBMITTED WITH THIS PLAN. M L SITE PLOT PLANIMAPPREVIDUSLYSUBMITTED.(EICCRPF 2 ma IV.TANK MONITORING IS PERFORMED USING THE FOLLOWING METHOD R LE OF ANNULA2.204) SIITW.)SPACEIS)OR SECONDARY CONT NNUAL I. CONNNUOWITH °9°'t AUDIBLE AND ARMS. VAULTS) WITH AUDIBLE AND VISUAL ALARMS. (Z3 CCR UO s90d n LED SECONDARY CONTAINMENTI5: ❑ °. DRY®_b. LIQUID FILLED O c. PRESSURIZED i] d. UNDER VACUUM _ PANEL MANUFACTURER: Veeder-Root 496' M_ODETV: TLSIM �u ° LEAKSENSORMANUFACMER:Veeder-Ram °90A' MODELg(S): 10E 44wo El lAUTDMVDCTANK GAUGING(ATG)SYSTEM USED TOMONITORSINCLRWALLTANKr31(23 CCR UZ643) 4° 3L MANUFACTURER: °90.11' MODELM 4ao•iP _PANEL --_ IN-TANKPROREMANUFACTURER: �___-- _ 4aw4. MODEL p(5)_ __—•.Y°0.° LRAKTESTFREQUENCY: ❑ &CONTINUOUS (:1 b. DAILYMIGHTLY ❑ c. WEEKLY ao-t4 (]d. MONTHLY � OTHER(SPaet¢L__ 4 17 PROGRAMMED TESTS: ❑ a.0.1 g.p.h. ❑ b, 02 gp.h. ❑ C. O'IHER(Spwafy): msa 4m-19 ❑ 3.MOIY1'HLYSTATOTICALMVENTORYRECONCILIATION(23CCRU2b4G1): 4°um ❑ 4. WEEKLY MANUALTANK GAUGING( HRG)(UCCRU2645). TESTINGPEMOD: ❑ a.36HOURS ❑ b.60HOURS Bs10io.2t� 6. TANK INTEGNTYTESTING rya CCR UZ64i.1): woa< TEST FREQUENCY: ❑ as ANNUALLY ❑ b. BIENNIALLY ❑ a OTHER (Speify): 4soD Hau ❑ 99. OTHER (Specify): 4m17 V. PIPE MONITORING IS PERFORMED USING THE FOLLOWING METHOD(§) (Check all OFF") I. CONTINUOUSMONORMUNG OF PIPFJ PIPING SUMP(S) AND OTHERSECONDARY CONTAINMENT WITH AUDIBLE AND VISUALALARM& (23CCR926M) MaP SECONDARY CON AR, MENT IS: ®a. DRY Ob. LIQUID FILLED [L3u PRESSURIZED Od. UNDER VACUUM PANEL MANUFACTURER; Veed4r-Aoot —^_ °90'J0 MODELg: TULIN 4ses: LEAK SENSOR MANUFACTURER: V_"der-Rant _R'a MODfiL B(3): 205_ _ PIPING LEAK ALARM TRIGGERS AUTOMATIC PUMP(i.c., TORKNE) SHUTDOWN. ®aYEm ❑b. NO ^°'J° FAILUREIDISCONNECTION OPTHE MONITORINOSYSTEMTRIGGERS AUTOMATIC PUMP SHUTDOWN. ®a.YES [I b. NO flows 2.M ICAL LINE LEAK DETECTOR(MLLD)'THAT ROUTMELY PERFORM93A g.p.h. LEAKTRSIS AND RESTRICTS OR SHUTS OFF PRODUCT FLOW WHEN A LEAK IS DEI'RCTED�'li CCR�.C6I6j_ __ .^_ 49aae 4mae MLLD MANUFACTURER(S): Rod Jacket °mar MODEL MS): F%N ❑ 3. LINE LEAK DETECTOR(ELLD)THAT ROBEWELYPERFORMS JA&pb. LEAK TESTS(23CCR§2061 4" ELECTRONIC ELLD MANUFACTURER(3) 4so-4a MODELg(SI: _ __ PROGRAMMED IN LINE LEAK TEST: ❑ I.MINIMUMMONTHLY0.2g.p•b. ❑ I MINIMUM ANNUAL 0.1 Ipob. 0041 ELLD DETECTION OF A PIPING LEAK TRIGGERS AUTOMATIC PUMP SHUTDOWN [I a. YES ❑b. NO ELLD FAILURE/DISCONNECTION TRIGGERS AUTOMATIC PUMP SHUTDOWN. El a. YES [I b. NO 414 4.PIPEINTF.GRITYTRSTING4 u ' TEST FRE UENCY &ANNUALLY ❑ b.EVERY3YEARS ❑ cOTHER(S a 4fo-464N'D 5. YISUALPIPE MONITORING. 0*41 FREQUENCY &DAILY b. WEEKLY ❑& MW,WWHLYA EACH rlI SYSTM OPMATM' 2,L a •AWn ! rvm fvl mlyicr#XMIs ❑ 6. SUCTION PIPING MEETS EXEMPTION CRITERIA 123 CCR 92636(03)F Ll 7. NO REGULATED PIPING PER HEALTH AND SAFETY CODE, DIVISION 20, CHAPTER 6.T R CONNECTLD TOTHLTANK SYSTEM o-n ❑ 99. OTHER (Specify) UPCF UST-D (12MQ7) IN UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK MONITORINGPLAN (Page2of2) VL UNDER DISPENSER CONTAINMENT (UDC) MONITORING 1. UDC MONITORING IS PERFORMED USING THE FOLLOWING METHOD Me Soa ❑ L CONTINUOUS ELECTRONIC MONITORING [12. FLOAT AND CHAIN ASSEMBLY N 3. ELECTRONIC STAND-ALONE ❑ 1_NODMPENSEI g E399. OTHFJI(SPej__ _ PANEL MANUFACTURER: Veetleo-ROotOOELNTLS] --i_ LEAKSNMANR kELa1gASOR I raga DETECTION OF A LEAK INTO THE UDC TRIGGERS AUDIBLE AND VISUAL ALARMS ❑ a. YES 29 It. NO W UDC LEAK ALARM TRIGGERS AUTOMATIC PUMP SH GMOWN ❑a.YES ®b.NO made. FAILURE DISCONNECTION OF UDC MONITORING SYSTEM TRIGGERS AUTOMATIC PUMP SHUTDOWN. ❑a. YES 0b. NO fl061 UDC MONITORING STOPS THE FLOW OF PRODUCTAT THE DISPENSER. ®a. YES ❑b. NO ram 04 1 UOC CONSTRUCTION IS ®I.SINGLE-WALLED 02. DOUBLE -WALLED _ IF DOUBLE WALLED: UDC IMEItSTIT1AL SPACE IS MONITORED BY: [31:_LgUID 2PRESSURE 3. VACUUM A LEAK WITHIN THE SECONDARY CONTAINMENT OF THE UDC TRIGGERS AUUIBLEAND VISUAL ALARMS ❑a.VES ❑b.NO VII. PERIODIC SYSTEM TESTING Lj I. ELD TESTING: THIS FACILITY HAS BEEN NOTIFIED BY THE STATE WATER RESOURCES CONTROL BOARD THAT EISBANCED ones. MUST BE PERFORMED. PERIODICELDISPERFORMEDEVERY36MONRdSABREQUIRE�.03CCR.g2694.D __6&AB.RFfFGI�NfELD 02. SECONDARY CONTAINMENT COMPONENTS ARETESTED EVERY 36 MONFRS. 3.EFlLL BUCKEIJ ARS TEBTED ANNUALLY. ^o"d' VDL RECORDKEEPING The owingmonilormgfmainknen mwrds an kept for tie lengthy: ®Alarm logs rw<ee ® Visual Inspection Records taaa ❑ Tank inseffity taking raalmaan¢ ❑ SIR testing results hand supporting doeumenmtion mamma. dweN ❑Ta gaugingsonit(mdsoppodi%dmumemntionmcords). asoem ®AM Testing results(and supporting dowmentation records). aw.ew Q Comenion Protection 60-day logs mpmo ® Equipnxel maintenance and eal3rDlon records. aw.an IX. TRAINING ® Personnel wit UST monitodtgresponstbilitee me famifarwithall ofNeeollowing document; mementos theirjob data, wo.wa REFERENCE DOCUMENTS MAINTAINED AT FACILITYU (Check all that apply) ® THIS UNDGROROUND STORAGE TANK MONITORING PLAIN (Required) woaul, ® OPERATING MAN LALS FOR ELECTRONIC MONITORING EQUIPMENT (Requirof Amw ® CALIFORN A UNDCItUltOUND STORAGETANK REGULATIONSaoamn ❑ CALIFORNIA UNDERGROUND STORAGE TANK LAW maaN ❑ STATE WATER RESOURCES CONTROL BOARD (SWRCB) PUBLICATION: "HANDBOOK FOR TANK OWNERS - MANUAL AND STATISTICAL INVENTORY RECONCILIATION"uw.ar ❑ SWRCB PUBLICATION: 'UNDERSTANDING AUTOMATIC TANK GAUGING SYSTEMS"eoo-mg ❑ O'fHER(SpecIIy):amsa Nml This fdulily ha n "DpignYod UST Opesabr"who hu taemd IIIc CallfamiellST Syscem Opaelor Exmn admininmea by to Inuamtioml Code Cownt IICCy The"Oesignaled UST Operator will pain f r ility amployecs in Into pmpnr openmion end readeananm ofthe UST syvborm annually, and within N drys orhim.Thn tminingwill Inciwle, bus is not limited to, the following: D Opmlionofthe USTs}Smmetnammmrn mntwlttefwlldy-ebalmmaggmentpimtcm D The facility employe'smlewith regard tolhe mmroitar'ng equipment m Specified in the UST Monitoring Pin ➢ The moiliry emplaya's mlewith raised m mills and ovcalses speeiEad m to LIST Reoponw Plan D Namaofconmu perwn(Ofor emergnoi"ned welering alrtns. aam X. COMMENTS/ADDITIONAL INFORMATION Pravideadonlonal comments here or indicatehow many pagawithaddtoMl inAmedon m apeciRctmnaorin8 Ptoecdumsaw ananlwdto thir plan. ran XL PERSONNEL RESPONSIBILITIES The UST Ownm/Opaawro ropenaible Rr ensaringthat U the tody/fougne UST mou0nng adevitia and meimermrec ofUST b ek demmion equip hunt wwmed by thopin oram.2)all conditions that ko icmaa possible mleaw am iwmtigasd aid 3) all monhosing reeoldhere maintained property. The following M wo(S) use tmponsih'e for perfanningthe mmitoringand equipment maintenance: NAME HATSaNlw Shmion 49nn TITLE Service Contrcemr l3 NAME 49 N TITLE awn The Designated ODD or hell pmkvn a muddy visual inmemim of the facility, provide a report m Bon owner/operdbr, nd'mfarm the owneh'epembr of my wtalkiormthatneed f 110 t . XII. OWNER/OPERATOR SIGNATURE CERTIFICATIO :Ice i that einform In prmided herein is lrocndaceoaletothe heetof knowledge. APPLICANTSIGNA URE dam ' DATE: Hpn r z-2! a aw . APPLICANT NAMF. (Prin ]: mom APPLICANTTITLE: ewac Noel Massie President UPCP UST-D (1YM(S1) 3f4 f4gamy Las Oak) Main plan laser loam mdmw mad: El Approved ❑ ApprWal with Crmaidans Laical Amami, Signnal Dean: Commwm m Spec ill Candisiom: UST Monitoring Plan — Page 2lnstruefions Complete a separate UST Monitoring Plan for each UST monitoring system at the (wilily. This form must be submitted with your initial UST Operating Permit Application and within 30 days of changes in the information it walains. Plcnsc note that your local agency may requite you an obtain approval color to installing or modifying monitoring equiplowL (Note: Numbering of these instructions follows the date element numbers on the form.) 490.54a MONITORING OF THE UNDER DISPENSER CONTAINMENT-IMicase the method mind for UOC monitoring. 490-541n. SPECIFYdrgq-,one a choked, derenEe other me0lon wan IfVl-1-I,VL1-3 or VI-1-3 or V14-99 is cheddL wmplde 490.35 in 49 41h. 490.55. PANEL MANUFACTURER -flew the Meow of the monufacwrer ofsM menimnngsystem aonlml peat(console). 11'lhera iano tomrol pond (a.&nasty an <laviml relay boa is i gualad)kealcarrieb err #i 490.56. MODELM . F4rur elm meld numbs Par We monimring systems central panel (consist, Hubert is no wntrol pawl (e.g., only an elenocel Nay Eox is Will leave this space Well 490.57. LEAK SENSOR MANUFACTURER —Enjoy elm name of me lmnufeuurer oflMsemoKa? 490-59, MODEL 6(S)-Enter lM model rwmer aft derer(s) imtalld. ifaWiucrml spom is traced, we Sodw X 490.59, DETECTION OF A LEAK INTO THE UDC TRIGGERS AUDIBLE AND VISUAL ALARMS, Indicate Yeaor No 490b0. UDC LEAK AIARMTRIGGERS PUMP SHUTDOWN- Indicate Yesar No 49051. FAILUREIDISCONNEC ION OF UDC MONITORING SYSTEM TRIGGERS AUTOMATIC PUMP SHUTDOWN - Indi¢re Ya or No 4Sl UDC MONITORING STOPS THE FLOW OF PRODUCT AT THE DISPENSER- Iro iwK Van or No. ".An 1=C0NKrRUCt'I0N-Ndimte if she wnslrvciaU oftle UOCksingl>wailed, ordouble-walled. lFVXA1�dHINJIDIN wo,86. TESTING OF SECONDARY CONTAINMI 490.69, SPILL DUCKETTESTING-Chest the box 4W69a %TRAINING RmttwoiRING PLhellstmati 4904f96 MPRATING MANUALS SMR 490.69c. OPERATING MANUALS MR 490k9d, CA UST REGULATIONS -Intl 49l CA STATE WATER - Indicate most rh 49ob9f. STAIE WATER IIESOURCC 49D9o. 49DT1. ramnldned for this f iliry. aodexrh rehr<me doeumarxs mainuinetl m the heiliry. Ndetleltme i1 kept m a raferexRdafYlMn1. PUBLICATION - "HANDBOOK FOR TANK OWNERS -MANUAL AND at this is kept ma remmnm docamem TANK GAUGING SYSTEMS": Iradimm this this is kept as a reference domi. any edddmml IbTayatma amnitorin6-r<leud mfomletian (u6. Mditianel . Ifadditional spear is nade4 see Section%. I Money) ofadditioamlpagceofinfo[OR YO todescribe ' menaY). NMch MY manhoring lomthss yea will beuory 490-M NAME -Emcrt M era r.... W.e.a.,_.... MmeoflMPerson who routinely c4ndRU rile ramitoringwd equimmmmairmnwtt odes this plan. 493-73. TITLE- Emp tie ride ofahepersoa 490-74. NAME -Esser the area of the sewed person, ifappllcaln1% who mminely condom the moserrig aM equipment msimenmce under this plan. 490.75. TITLE Enlcr De mle fifth<swml permn. OWNERIOPGRATOR SIGNKW RE -The Nnk ouawrogSwor, redlity ownerhperiaL man amhbriad mpfeammtive ofine owner still seder in (an move Provided. This sigreaure cal lac mass no signal believes that all hirevi calm wbmined is vas awamlc, ad eompleN, end that the aeiningpregrmn specified in Salon Was been imchawried 490-76. REPRESENTING- Cheda the appropriate beat to iamicate whether the signer k Oar UST ounerlopemlu9 the UST facility oameopraA04 cram wthomed representative orthe oaran. 490-]]. DATE- Enter the date the plan WanVgned. 490-79. APPLCANT NAME- Pont d type the acme of0e person Ageing ill*plan 49od9. APPLICANT TITLE- Enter the tide 4 the person ogling One plat. UPCF LIST-D (112WT) 464