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(Agency Use Only) This pl t been re '•wed ' �PProved ❑Approved With Condif s Local Agency Signal= Comments or Special Conditions: Date: 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 local agency may require you to obtain approval prior to installing or modifying monitoring equipment. (Note: Numbering of these instructions follows the data element numbers on the form.) 490.54a.MONITORING OF THE UNDER DISPENSER CONTAINMENT- Indicate the method used for UDC monitoring. 490-54b.SPECIFY-If 99"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 490.646. 490.55, PANEL MANUFACTURER—Enter the name of the manufacturer of the monitoring system control panel(console). If there is no control panel(e.g.,only an electrical relay box is installed)leave this space blank. 490-56. MODEL q- Enter the model number for the monitoring system control panel(console).If there is no control panel(e.g.,only an electrical relay box is installed)leave this space blank. 490.57. LEAK SENSOR MANUFACTURER—Enter the name of the manufacturer of the sewor(s). 490.58. MODEL NIS)—Enter the model number of the sensor(s)installed.If additional space is needed,use Section X. MS 490-59. DETECTION OF A LEAK INTO THE UDC TRIGGERS AUDIBLE AND VISUAL ALAR . 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-Indicate 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. 490-64a.DOUBLE-WALLED INTERSTITIAL SPACE MONITORING- Indicate what is used to monitor the interstitial space. 490-64b.LEAK WITHIN THE SECONDARY CONTAIMENT OF UDC TRIGGERS AUDIBLE AND VISUAL ALARMS-Indicate Yes or No 490.65. subject to 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 this plan istare 490.66. TESTING OF ECONDARY CONTAed Leak Detection I9NMENT uirements COMPO rMPONENTS RMONTHS IHant and is located within 1,000 fat of a public drinking water well). 490.67. SPILL BUCKET TESTING-Check the box if you have spill buckets.EVERY 366 ONTCheck the box if you have secondary containment that requires testing. 490-68a-h.VIII RECORDKEEPING-Indicate which monitoring and equipment maintenance records am maintained for this facility. 490-69a IX TRAINING STATEMENT-Check the box to verify that the statement is true. 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 must 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 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 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 a reference 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 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(e.g.,additional information required by your local agency). Attach any monitoring logs that you will be using for the mormoring of yaw tank system. 490.72. NAME—Enter the name 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 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 that 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/operator,the UST facility owner/operator,or an authorized representative of the owner. 490-77. DATE—Enter the date the Plan was signed. 490.78. APPLICANT NAME—Print or type the name 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