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=Only) TbisThis plan lids been reviewed and. Approved ❑Approved WithConditions ❑Disapproved A/M►�-NDate: << 10G ditions: UPCF UST Monitoring Plan—Page 2 Instructions ComQete a separate UST Monitoring Plan for each UST monitoring system at the facility. This form must be submitted with Your initial UST QpgMttM Permit Application and within 30 days of changes in the information it contains. Please note that Your local agency ural reamre you to obtain approval prior to Inst lin or rnnd,fvrnu momtonng egmyment (Note Nnbermg of these mstractnons follows the data element numbers on the form. —IOD(g) Cheek MONITORING OF THE UNDER DISPENSER CONTAINMENT-Indicate the method used for UDC monitorina- r aAnnTTTnnrnrr'Ae C�TfT'!'TC[T TF_ A(1(1 5 brief- F`he addery 490-54b. SPECIFY- If 99 ,ot is checked, desrnbe other method used_ ��—a=� ff VI 1 1 VI-1-2 or VI-1-3 or VI-1-99 is checked-complete 490-55 to 490-64b_ 490-55. PANEL MANUFACTURER Enter the name of the mamrfacturer of the monitorin¢system control panel(console). If there is no control panel(e s only an elechical relay box is installed)leave this space blank Ta r.A^?i oa-="•a"a oFACTURER If item:90=`:�__ _. h_ �= r Fa 490-56. MODEL# Enter the model number for the---t-=system control.el(console) if there is no control navel(M-only an electrical rclav box is installed)leave ibis s2ce blam&LMQDBL,#—W-iIemr49Q 5 4 t iis..r T z F r 4he FfigF-r:s '=PaWL 490-57. LEAK SENSOR MANUFACTURER ENra the name of the manufacturer of the seasor(s)rec.Tenn;.r jT W Tc A np Wa g..,..,-env 54a I e-490 54-a- - qF;F(-S).,Ifffi a8e iS 3 is ebee SP 9 item 490 5 U 1 er-490 5 4&3 is 490-58. 4_- 490-58. MODEL#(S) Enter the model number of the sensor(s)installed.If additiopal space is needed.use Section TRE TlT_'TPl-'TinAT/lC A LEAK AT/TATTn l: 490-59. ETECTION OF A LEAKT TINAT*OTTTS-T�HE TUDC TR1G�G�ERS AUDIBLE AND VISUAL ALARMS. Indicate Yes or No.)1 J-DETEo T TDTI'' D AT QTS' rD CTS�y�y y��`T Gl.eek Vele-Ne 490-60. UDC LEAK ALARM TRIGGERS PUMP SHUTDOWN-htdicate Yes or NoT c Aa_q6b- D -ALARM TPJGG TnrxrD 81 r�nE:wro �x_a_v _ NO, 490-61. FAMUREIDISCONNECTION OF UDC MONITORING SYSTEM TRIGGERS AUTOMATIC PUMP SHUTDOWN - Indicate Yes or No-VALL 490-62. UDC MONITORING STOPS TIE FLOW OF PRODUCT AT THE DISPENSER-Indicate Yes or No. pp -UR16.��LEAK DETECTION? Ghede-�� 490-63. UDC CONSTRUCTION Indicate if theTconstruction of the UDC is shale-waned.or double-waned 490-64x.. DOUBLE WALLED INTERSTITIAL SPACE MONITORLNG-Indicate what is used to monitor the interstitial space�t�T��€Lha S$�K$isS-4€yes T A 490-64b. LEAK WM-HN THE SECONDARY CONTAIlsA�IENT OF UDC TRIGGERS AUDIBLE AND VISIiAL ALARMS-Indicate Yes or No-� r n_TDnTrn�T nr Im RFR&ODIG 9VSTFsAR TR.STPiG 490-65. VII-1 ELD TESTING-Check the box if you have been notified by the State Water Resources Control Board(SWRCB)that the UST(s)covered by 8»s plan is/are subject to Enhanced Leak Detection Reauir O!§fie..UST has a,tv ' ,e-wail component and is located within 1.000 feet of a public drinking water well).ELD 490-66. TESTING OF SECONDARY CONTAINMENT COMPONENTS EVERY 36 MONTHS - Check the box if you havewcondary cm&mment that requires t testingeestaim eempeneels that fife fleet ,.r.,n 490-67. SPILL BUCKET TESTING-Check the box if you have spin bucketsopn r BUCKET T .T T-ESTLNG You mEIA elePl�N and r 'd UST-F.1, tr rnA'T'S'nD TAT/ A r A TATTETT M1 AT(•T: 490-68. VIII RECORDKEEPING hulicate which momtmmg and ege Mment maintenance records are maintained for this Facilitv� KC-TRAANEgG 490-69a.IX TRABUNG STATEMENT-Check the box to vetify that the statement is true- REFERENCE DOCUMENTS MAFNTAWW AT FAC1LrrY Check the aporovriate boxes to describe reference doemnents maudamed at the facilgy `that the F with Ug:p b r first two items on the list must be kept at the facility. [';� `a=�-r --.e . s fer- item 490 69b d3feu@ft h te ideafifY fefi-Tefiee deeunwiAs that are elaietained FA- with Felevant feeiW Ne4e that items non rni. .a.. re .._"e 490-69b. MOrIITORING PLAN-hKhcate that this pin is kept as a reference document 490-69c. OPERATING MANUALS FOR ELECTRONIC EQUIPMENT-Indicate that this pian 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 docmnenL 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 docmueaL 490-69P SWRCB PUBLICATION:"UNDERSTANDING AUTOMATIC TANK GAUGING SYSTEMS":htdicate that this is kept as a reference document 490-69h. OTHER-Indicate that other referm=doc=ents are kept UPCF USP-D(1=007)-516 www.unidoes.org