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(Aganty Use Only) This plan hash ad and;- '10Approved Approved With CoetdidorW- I Local Agency Sigptttum. r� Comments of Special Conditloas Date 45 _-- UST Monitoring Plan--Page Z Instructions Complete a separate UST Monitoring Plan for each UST monitoring system at the facility. This form must he Submitted with your initial UST Operating Permit Application and within 30 days of changes in die information it contains. Please nota: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.) 490-541.MONITORING OF THE UNDER DISPENSER CONTAINMENT-Indicate the method used for UDC monitoring. 490-54b.SPECIFY-If 99"Dthed'is checked„describe other method used. If VI.I.1,VI-I 3 ar VI-1-3 or VI-1-99 is checked,complete 490-55 to 490-64b. 490-55. PANEL MANUFACTURER-Enter the name of:he manufacturer of ibe mooacring 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#- 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)Ieave this space blank. 490-57. LEAK SENSOR MANUFAC URER-Enter the name ofthe manufacturer of the sensor(s). 490-58. MODEL*(S)-Enter the model number of the sensor(s)installed.If addhional space is needed,use Section X. 490-59, DETECTION OF A LEAK INTO THE UDC TRIOGERS AUDIBLE AND VISUAL ALARMS. Indicate Yes or No 490-60. UDC LEAK ALARM TRIGGERS PUMP SHUTDOWN'- Indicate Yes or No 490-61. FAILUREIDISCONNECTION OF UDC MONITORING SYSTEM TRIGGERS AUTOMATIC PUMP SHUTDOWN-Indicate Yes or No 490-62. UDC MONiTORLFIG STOPS THE FLOW OF PRODUCT AT THE DISPENSER-Indicate Yes or No. 490-63. UDC CONSTRUCTION- Indicate if the construction of the UDC is singlc-walled,or double-waNled. 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 14C 490-65. V1I-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 pian is/are subject to Enhanced Leak Detection Requirements(i.e.,UST has any single-wall component and is located within 1,:)00 feet of a public drinking water well). 490-66. TESTING OF SECONDARY CONTAINMENT COMPONENTS EVERY 36 MONTHS-Check the box it'yeu have secondary corrtairunent that requires testing 490-67. SPILL BUCKET TESTING-Check the box if you have spill'buckets. 490-68a-h.VIII RECORDKEEPING-Indicate which monitoring and equipment maintenance records are maintained for this%ciliry. 490-69a EX TRAINING STATEMENT-Check the box to verify that the statcrncnt is true- REFERENCE DOCUMENTS M-AJNTAINED AT FACILITY-Check the appropriate boxes to describe reference documents maintained at the dicihty. Note the the first two'items on the list must be kept sl 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. 490-694. 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.S WRCB PUBLICATION:"UNDERSTANDING AUTOMATIC TANK GAUGING SYSTEMS Indicate that this is kept u a reference document. 490-69h.OTHER-Indicate that other reference documents are keot. 490-69t. SPECIFY-If"OTHER"is checli:4 mier a brief description of the other documents)tnaintained at the facility.If additional space is needed,we Section X. 490-70. DESIGNATED OPERATOR TRANING-Check this boa to verify that this stalemerx is true. 490.71. COMMENTSMADDITIONAL INFORMATION-Make additional comments or you may attach and identify the number of additional pages cf information to describe any additional UST system monitoring-related infomatim(e,gw additional information required by your local agency). Attach any monitoring logs that you will be using for the monitoring of your rank 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 perstm. 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- Eater the title of the second person. OWNERIOPERAT'OR SIGNATURE-The tank ownerioperator,facility owner/operator,or an authorized representative of the owner shall sign in the space provided. This signature certifies that the signer believes that ail information submitted is Iruc,accurate,and complete,and that the training program specified in Section M has been impkmettted. 490-76. REPRESENTING-Check the appropriate box to indicate whether the signer is the UST owner/operator,the UST facility owner/operator,Dr an authorized representative of the owner. 490-77. DATE-Euler the date the plan was signed. 49048. APPLICANT NAME-Print or type the nacre of the person signing the plan. 4190-79. APPLICANT TITLE-Enos the title of the person signing the plan. UPCF UST-D(12!2007)AJA