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07/07/2011 08:55 2097270859 GEORGE'S #1637 P.004 /004 <br /> .......... <br /> .......... <br /> ... ....... <br /> a <br /> Me. <br /> UST Monitoring Plan—Page 2 Instructions <br /> Complete a separate UST Monitoring Plan for each UST monitoring system at the facility- This frention must be submitted with your in" UST <br /> Operating Permit Application and within 30 days of changes in the inAmriation it contains. Please:note that your local agency may require you to <br /> obtain approval nrigr to installing or modifying monitoring equipment, (Note; Numbering of these Instructions follows the data element numbers on <br /> the form.) <br /> 490-54a.MONITORING OF THE UNDERDISP04SER CONTAINMENT-lialicamthoundhod used for UDC monitoring <br /> 49044b.SPECIFY-1f99'Other"ischocked,describe other method used. <br /> If VI-1-1,VI-1-2 or VI-1-3 or VI-1-99 is decked,complete 490.55 to 490-64b <br /> 490-55. PANEL MANUFACTURER-Eour the new of the manurfinuter of the monitoring systerin control panel(console). If them is no control Panel(e.g.,only an elchical <br /> relay box is installed)leave this space,blank. <br /> 490-M. MODEL Enter tlx model number for the monitoring System control we](coamle).If fincro is no control panel(e.g.,only an electrical relay box is instancer,leave <br /> this <br /> space blank. <br /> 490.57_ LEAK SENSOR MANUFACTURER-Enter the name of the malufaexluer of the smsw% <br /> 490-58- MODEL#(S)-Enter the m0d0l number of the sons er(s)installed-If ailditionall space is needed,use Section X <br /> 490-59 DETECTION OF A LEAK INTO THE UDC TRIGGERS AUDIBLE AND VISUAL ALARMS. Indicen:Yes or No <br /> 49050 UDC LEAK ALARM TRIGGERS PUMP SHUTDOWN- Indican;Yes or No <br /> 49051. FAILUREIDISCONNECTIONOFUDC MONITORING SYSTEM TRIGGERS AUTOMATIC PUMP SHUTDOWN-Indicate Yesor No <br /> 49062. UDC MONITORING STOPS THE FLOW OF PRODUCT AT THE DISPENSER-Indicate Yes or No. <br /> 49063. UDC CONSTRUCTION-Indicate if the construction of the UDC is single.waned,or double�walled. <br /> 49064S.DOUBLE-WALLED INTERSTITIAL SPACE MONITORING- l3diCalb what is used to monitor the inaersIftaI Space. <br /> 490-64b LEAK WITHIN THE SECONDARY cohrrArMENT OF UDC TRIGGERS AUDIBLE AND VISUAL ALARMS-Indicate Yes or No <br /> 490-65, VB-1 MD TESTING-Check the box ifyou have been notified by the State Water Resources Cowed Board(SWAGS)thatthe UST(s)covcred by this plan W= <br /> Subject to Enhanced Leak Detection Ihiquiterocies(Le.,UST has Sony single-wall conewoncia and is located within 1,000 foci:of apublic drandchig;Water well). <br /> 49066. TESTING OF SECONDARY CONTAINMENT COMPONENTS EVERY 36 MONTHS-Check the box if you have SOCOndmY containment that requires testin& <br /> 490-67. SPILLBUCKET TESTING-Check the box ifyou have spill buckets. <br /> 49&6&a-h.VIE RBCORDKEUMG-Joeiicaw vilinh m0ndming and equaimneor mainumance,records me maunciamed for this facility. <br /> 49669a DC TRAINING STATEMENT-Check the box to ver*that the alinement is[nuc. <br /> REFERENCE DOCUMENTS MAINTAINED AT FACILITY-Check the appropriate boxes to describe reference documents anamat ned at the facility. Note that the <br /> first two leaves on the list MV be kept at the facility. <br /> 490496. MONITORING PLAN:Indicate that this Plan is kept as a reference documcat <br /> 490-69c. OPERATING MANUALS FOR ELECTRONIC EQUIPMENT:Indicate that this plan is kept as a reference documon. <br /> 49069(L CA UST REGULATIONS-Indicate that this is kept as a reaJetwo:documera. <br /> 49069e- CA UST LAW-indicate fliettlas is kept as a ralorcric;docureem. <br /> 49"N STATE WATER RESOURCES CONTROL BOARD(SWRCS)PUBLICATION- -HANDBOOK FOR TANK OWNERS-MANUAL AND <br /> STATISTICAL INVENTORY RECONCILIATION-Indicate that this is kept as arefbrethae document <br /> 490698,SWRCB PUBLICATION:"UNDERSTANDING AUI-OMA11C TANK GAUGING SYSTEMS";Indicate,that this is kept as areference docnancrit <br /> 49069h,OTHER-Indicate thallother reknatem doctimaints;are kept <br /> 490-691. SPECIFY-If"OTHER"a checked,enter abnef description of the otherdocumcna(s)maintained attho facility.If additional space is noodod,See Seedcan YL <br /> 490.70- DESICNATED,OPERATOR TRAINING-Check this box to vmfylw thm statement is mm. <br /> 490-71- COMMENTS/ADDITIONAL INFORMATION-Make additional commeM or you may attach and identify the number of additional pages of information to describe <br /> any additional UST system mortitorixig-rutmod mitermationt(e.g,additional information required byyouir local agency). Attach a"monitoring lop that you will be wing <br /> for the monitoring ofyoureark System. <br /> 490-72. NAME-Erverthename of the person who routinely conducts the monitoring and egrdpmcnt maintenance undcrijus plan. <br /> 490.73. TITLE- Euterthe tide of the person- <br /> 490-74.NAME-Enter the nem;of the Second person,if applicable,who routinely veriducts the monitoring and oquiterievellicanweence under this plan <br /> 490-75- TITLE-lintarthe tale of the Second person. <br /> OWNER/OPERATOR SIGNATURE-The tank owner/operator,fitcihty owner/operator,man authorized repmenalow of the owner Shall sign in flicspace provided, <br /> This Signature cerfifics 00 the Signosr belicvcs that aft information Submitted is nue accurate,and complete and that the heading program Specified in Section IX W <br /> been implemenlecl. <br /> 490-76. REPRESENTING-Check the appropriate boat to Indicate whadher the signor is the UST owner/operator,the UST facility owner/opmexer,or an <br /> authorized represcutaeorm of the owner. <br /> 490-77. DATE-Bow the date the plan was signed. <br /> 49478. APPLICANT NAME-Print or vAx the name of the person signing the plan. <br /> 49479. APPLICANT I=--Entente title of the Person signing the plan. <br /> IMrm V _"III Mmn'Th AIA <br />