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(Agency Use Only) This plan has ban r ie/wad and 5IApproved ❑Approved With Conditions ❑Disapproved Local Agency Signatme: + /v/z}7'�/�1n Date: 0 f��/ I Z Comments or Special Conditions: UPCF UST Monitoring Plan —Page 2 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 Racal agency may require you to obtain approval priar to installing or modifying monitoring equipment. (Note: Numbering of these instructions follows the data element numbers on the form.) 490.54& MONITORING OF THE UNDER DISPENSER CONTAINMENT-Iu bcah,the method used for UDC monitoring 490-54b.SPECIFY-11799"Other'is checked,describe other method used. If 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 manufacturer of the monitoring system central panel(wnsole). If there ism control panel(e.g.,only an electrical relay box is installed)leave this space blank. 490-56. MODEL#-Enter the model number for the monitoring system control panel(console).Ifihere is no control panel(e g.,only an electrical relay box is installed)leave this space blank. 490-57. LEAK SENSOR MANUFACTURER-Enter the came of the manufacturer of the smsor(s). 490-58. MODEL#(S)-Enter the mode(number ofthe sensors)installed.If additional space is heeded,use Section X. 490-59. DETECTION OF A LEAK INTO THE UDC TRIGGERS AUDIBLE AND VISUAL ALARM$. Indicate Yes or No. 490-60. UDC LEAK ALARM TRIGGERS PUMP SHUTDOWN-Indicate Yes or No. 490-61. FAILURE/DISCONNECTION OF UDC MONITORING SYSTEM TRIGGERS AUTOMATIC PUMP SHUTDOWN-Indite,Yes or No. 490-62. UDC MONITORING STOPS THE FLOW OF PRODUCT AT THE DISPENSER-Indicate Yes or No. 490-63. UDC CONSTRUCTION-Indicate if the construction of the UDC is single-walled,or double-walled 490-64& DOUBLE-WAILED INTERSTITIAL SPACE MONITORING-Indicate what is used to monitor the interstitial space. 490-64b.LEAK WITHIN THE SECONDARY CONTAINMENT OF UDC TRIGGERS AUDIBLE AND VISUAL ALARMS-Indicate Yes or No. 490-65. VI-1 EIA TESTING-Check the box if you have been notified by the State Water Resources Control Board(SWRCB)it=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 of a 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 if you have spill buckets. 490-68. VIII RECORDKEEPING-Indicate which monitoring and equipment maintenance records are maintained for this facility. 490-69x. IX TRAINING STATEMENT-Check the bolt to verify that the statement is nue. REFERENCE DOCUMENTS MAINTAINED AT FACILITY-Check the appropriate boxes to describe reference documents maintained at the facility. Note that the first two items on the list mug be kept at the facility. 490-69b.MONITORING PLAN:Indicate that this plan is kept as a reference document 490-69c. OPERATING MANUALS FOR ELECTRONIC EQUIPMENT:Indicate thin this plan is kept as a reference document. 490-69d.CA UST REGULATIONS-Indicate Nin this is kept is a reference document 490-69e. CA UST LAW-indicate that this is kept as a reference document. 490-69f. STATE WATER RESOURCES CONTROL BOARD(SWRCB)PUBLICATION- "HANDBOOK FOR TANK OWNERS-MANUAL AND STATISTICAL INVENTORY RECONCILIATION':Indicate that this is kept as areference document. 490-69g.SWRCB PUBLICATION:"UNDERSTANDING AUTOMATIC TANK GAUGING SYSTEMS":Indicate that this is kept as a reference document 490-69h.OTHER-Indicate that other reference documents are kept. 490-69i. SPECIFY-If"OTHER"is checked,enter a brief description of the other document(s)maintained at the facility.If additional space is needed,see Section X. 490.70. DESIGNATED OPERATOR TRAINING-Check this box to verify that this statement is true. 490-71_ COMMENTS/ADDITIONAL INFORMATION-Make additional comments or you may attach and identify the number of additional pages of information to describe any additional UST system monitoring-related information(cg.,additional information required by your local agency). Attach any monitoring logs that you will be using for the monitoring of your lank system 490.72. NAME-Enter the time of the person who routinely conducts the monitoring and equipment maintenance under this plan. 490-73. TIME-Enter the title of the person. 490-74. NAME-Enter the name of the second person,if applicable,who routinely conducts the monitoring and equipment maintenance under this plan 490-75. TITLE-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 Nat all information submitted is true,accurate,and complete,and that the training program specified in Section IX has been implemented. 490-76. REPRESENTING - Check the appropriate box to indicate whether the signer is the UST owner/opemmr, the UST facility owner/operNor, or an authorized representative of the owner. 490.77. DATE-Enter the dam the plan was signed. 490-78. APPLICANT NAME-Print or type the time of the person signing the plan. 490.79. APPLICANT TITLE-Enter the title of the person signing the plan. UPCF UST-D(12!1967)-414 www.unidoc&org