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<br /> UST Monitoring Plan—Page 2 Instructions
<br /> Complete a separate UST Monitoring Plan for each UST monitoring sysonn at the facility. This form must be submitted with Yow ittatial UST
<br /> Opaaing Permit Application and within 30 days of changes in the information n contains. Pleue note that your local 99000Y MY rwPma you to
<br /> obtain apprava triol to insmiimg or modifying inmita-ing cquiPnwnt" (Note: Nwnbering of those instmetims follows the data element»umbes on
<br /> the form)
<br /> 490.54a.MONITORING OF TRE UNDPA DISPFNSL-•R CONfAINMENI--Im iwe the Inathod Ilcod for UDC UsQnilerirhg.
<br /> a9A54d SPSCIEti'-tt99'Oma"s chnekm,cane+he clan,nahod w.od.
<br /> If Vi-1-1,V{-I Z a V1-1-3 er V 1-1-99:s ebcckcd,comPkse 490.55 to 49p.64b.
<br /> 49055. PAHA MANl1FACTURPR-Erie'the,»rtro ofdw mamOhetrrter d,tiro morhkorinv_synan mntror panel(coreole). if tr is Ica mnvrol Pend(cg.,mly m eim*ieal
<br /> relay box w haaafd)leave ibis apace blank.
<br /> 49034 MODEL 0- Greer the npOtl nu fa the monitoring 1K control pM4L(txakok)-1f db is no 000trol Panel(ag.,only an cketrical ropy boxy WA21 3)ice"'
<br /> tris
<br /> vaic bbaL
<br /> 49037, LEAK MOM MANUFACTURER-Ede rhe Imre of be ma,ufaada,ofthe staraogs').
<br /> 490.5& MODEL II(S)-fisx the tnO":camber of the s�a(s)+oatalkd.If pW""oat space it,xNW,uao Section X.
<br /> 49039. OE ftC'TLON OFALFAK INTOTILE UDC TRIGGERS AUDIBLE,'.AND VISUAL ALARMS. k iacc Ycsar No
<br /> 490.60, UDC LEAK ALARM TRIQGERS PUMP SHUTDOWN- Indian'Yes or No
<br /> 49061. FAILURFIDISCONNECT1014 OP UDC MONn'ORINO SYSI EM'OtIGGERS At,70MA IV.PUMP SHUTDOWN-Imlieste Yes at No
<br /> 49062 UDC MorilnMING STOPS THE FLOW OF PRODUCT•AI THE DISPLNSL•R-Indiede Yes or No.
<br /> 490.63. UDC CONST' UCx N• IOd:eua Inbe<dnarrwkal Done urx is ynglo..vakd or double-walked
<br /> 490640-.O"LE-WAILED ItrTFitSTrFiAl SPACE MON1TOWNO- Indicate venal s ,w n"n"dre inaerstinal mance
<br /> 496.64b.LEAK WITHIN THE SL-CONDARY CONTAIMFNT OF UDC TRIGGERS AUDRLLE AND VISUAL ALARMS-lndicatu Ya m No
<br /> 49066- VII-L ETD TESTTNG-C,tck the box if you haw been nottfied by the Sato Wamr Reromtrs Caurol Hod(SWR(.'R)that the USIYs)co-'e'd by chs Plan ign c
<br /> atblim w Efthiswed Leak DClCipp R tS(I"C.UST has my staltic-wall=Voreatt and is beaten within 1-000 that of a pubtk dnnlmtg,xear wed),
<br /> 49066. TESTING OF SECONDARY CONTAINMENT COMPONENTS EV FRY 36 MONIIIS.Chock the box if you haw sworAwy rx ata trw nxpkm wade&
<br /> 49067. SPILL SL"Ef TGSTING-Cbmk rhe bac if you law spin backer,
<br /> 490.6a,4t VW R13CORDKI!EPING-Indiemc wneh,matenng and egaipn era:noidwurrca records aro Ina"a"r4d for this facility.
<br /> 490-69a IX TRAINING STATEMENT-Check the boa to verify that the stat'e'd IS to n
<br /> REfPREHCE DOCUMENTS MAMTA W h-D AT FACILITY-Cnak the approprNre bozo to dcscnbe reference dawn M namairad at the ScRny. Notetbt the
<br /> Gm two 4c as m the list auga he kcar at rise fadtitY.
<br /> 490.6%. MONttORING PLAN:I,.d:ms vast chis plan is kept as a,nfereree doemter l
<br /> 490-69. OPERATING MANUALS FOR ELECTRONIC FQUIPMENT Irdkme vhm:lad Vlan is kept a a re2asrecdaauncd-
<br /> 490A9k& CA USF ReOULATtONS-hidicafe tbal this is kep,sal a xc6x trm(keumcnt.
<br /> 490.6'',_ CA UST LAW.indicate than this s kept as a reit a docarnml.
<br /> 49639!STATE WATER RESOURCES CONTROL BOARD(SWRCB)PUBLICATION- -HANDBOOK FOR TANK OWNERS-MANUAL AND
<br /> STATLMAL INVENTORY RECONCILIATION-badicatc that this n kept as a cnk,enM 4xnrlent.
<br /> 490398.SWRCB PUBLICATION:-UNDERSTANDING AUTOMATIC TANK GAUGING SYSTEMS l4di terhal this is kW ns a tcfetdltc dxaasnt
<br /> 49039h"OTHIR•Indicate 00 orbs rckrcrlcc d,7cunh01015 aro kcpl.
<br /> 490L9i. SPECIFY.if-OTHER"is dhedra L Cala a brief de cripwwt of fire mhp documnti(s)imiwined an the facithy If sddWorg i sPW is trcedcd,sea$'Gori X.
<br /> 490-70, DESIONA'fED OPERATOR TRAININO-Cho*this bar to wrify that this statrmentis true
<br /> 49x71. COMMENT'S/ADOD70NAL INFORMATION-Make additional c0owwals c ym trey atach and identify the number of addttiorel Pages or16 bslnou!o rkbn usi
<br /> any adNtiorAl USf system manrtenng-rUated mfom»tion fog.., El i infmrvlion rvxplird by)car baa zgfareYl. Attach any rtharildahg logs enM yw w"i Iz,ax+g
<br /> kr the vwonilaue rs,a wfyorank system. bshdcwracw vac=th:x pan.
<br /> 490.72. NAME-nnac Lha rehnc�of the Pttaoe who r n,ecly CNS l7C mmoaiwring ad ec)agP
<br /> 490-73. TITLE• F hs the tick of the Prhsdn.
<br /> 490-74. NAME-Eotc the,ruse of the 9=0W Person-if applicable•wt*rwerahery ee r wjs the Inonhotin8 and ewuipaan,rein,maacc ardct This Pan.
<br /> 49075. TTrLE- Free ine,ifht of the sizwM peraon.
<br /> OWNEJWPERATOR SIGNATURE-The lank awner/oMator,facifiry of mer/opehirlor,of nt au[Ihorined rcp,csvh,an.eownhg shall sips k�teaSeKY provr0ed-
<br /> Tbis si�.tlmc cani0es rM vhc stgncr belie ,hah all infotnalion sobuiited Ls tore,acwrate.and complete,and that the paining Progarl 3PKt(1 d m Section IX has
<br /> been trapim t-d.
<br /> 490-76. REPRESENTING--Cbmk the appropriate bw 10 urdicsm,,he h,tM sig=is 11w USIownca/opaator,lane UST facility owrcr/operates•oven
<br /> arrlhari,to nwelcnuaixw of its owoc.
<br /> 49077. DATE-Er ten date the plan was siinred.
<br /> 490.79- APPLICANT NAME-Prim 0-r type the name of nhe Wnon aigntr%the plan,
<br /> 490-79_ APP(.fCANT TrIlE-Eaw'he'itk of qw prion signing the Pae
<br /> VPCP LTSf-B flZrA@7)414
<br /> CLO/010 d 46ZOA eoeld�ejLeN RL}unoo 9ZZZLb660ZL ZZ:9L OLOZ/40/40
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