Laserfiche WebLink
(,4g, y Ike(.a ted 7 hiisspplmn has been reviewed nsr App[wed ❑Approved With Cnndirem, {_a, <br /> 1 rxxl i m I'McIaum T/�(4(1/�(1� ✓ �__(1V�Daze' ✓( _ _ <br /> 1.1 Age m Speed Candlbms / G <br /> UST Monitoring Plan—Page 2 Instructions <br /> Complete a separate UST Monitoring Plan for each IIST Immttoring system at the facility- This form must he submitted with your initial UST <br /> Operating Permit Application and within 30 days of changes in the information it contains. Please note that you local agency may require you to <br /> obtain approval prior to installing or modifying monitoring equipment. (Note! Numbering of these instructions follows the data clement numbers an <br /> the form.) <br /> 49654, MONITORING OF TNI,UNDER DISPFNSFR CONIAI NMENI-Militate ter methal used 6u UDC nomination, <br /> 490.146 SPECIFY-11`99"Oilerrschecked,deacnhe mb.mdho i used <br /> IIVI-t•1 VL1.2wV1-1-3or VI-1-9r)rscbwkd,compinc490-55to490464b <br /> 49655 PANf1 MANIfFACT IIRFR-Lone the name of tic nan..riawmrnfthemonnonng,,rcmcontral Peed.,(console} 1Ctlerrrrsooemntrol panel le g only an denreal <br /> relay box is most led)leave this space blank <br /> 4q9-56 MODEL a- Enter[fie model no other fm the monitoring system Lotrel panel Iconsolet II there is no conlsol pond I g,only an electrical relay Ma ns meal led)leave <br /> this <br /> space blank <br /> 490-57 1IAK SFN.(' RMANUFACTURER-Lalcrthe,done of the maufaeturer of the senmr(s) <br /> 49658 MODFL N(S)-Feer the model number of the sucsorts)installed If aAdntsmal space is needed,use Section X <br /> 490-59 DEILCfION OF A l EAK IN CO THE Ulll' I KILLERS AUDIBI E AND VISUAL ALARMS adnanc Yn m Nn <br /> 490-60 UDC LLAK ALARM TRIGGMS PUMP SHUTDOWN- Imucmc Yam Ne <br /> 490-61 FAILURET)ISCONNECTION OF UDC MONITORING SYSTEM TRIGGERS AUTOMAOC PUMPSIRITDOWN-Indicate k'esm No <br /> 490-62 UDC MONITORING SEOPS THE FLOW OF PRODUCT AT THE DISPENSER-Indicate Yes se NO <br /> 49463 UUCC'UNSIRUL-11014- ladmcare if the consuuntan of me UfX'rs single-wa7ld,ordoultowa/1eJ <br /> Ica 64a DOUBLE WALLEDINILRSTITIAI SPACFh1flNlMRrNG- Indicate whnus used w ononimrahemterstBrel space <br /> 496 64b LFAK WI ININ THF SECONDARY CONTAIMFNT OF UDC 1RIGUFRS AUDIBLE AND VISUAL ALARMS-Indicate Yam No <br /> 490.65 VII-I ELI)lFSTING-Check the box it you he,.been notified by the elate Witter Resources Camel Board(SWRCH)thinthe ilS Its)caudad by flus plan ter am <br /> rabyaa lei FiimrrW teak Detemmn Rulmcancnts li c,1!ST has any single-wall cmnponeor aril rs IaoMd within I,OW feet ata pone drinking nater)sell) <br /> 49666 TESnNGC*SFMNDARY CON IAINMENf COMPONENTS EVERY 36MONTHS-Chsak thebos ifymt hasesecondary containment that rcgmn:S 1cvme, <br /> 490.67 SPILL BUCKET TESTING-Check the box ifyou base spill hackers <br /> 490-6ga-h VIII RF.CORDKEEPING-Indrme whch mumtonrsg and egmpmrnr mmnrnan[e recurJx sic nauuamd t r ihu Cmdny <br /> 491"On IX TRA1NINO STAT'E'MENT-ChccL the box at verify thin the statement ns true <br /> RPFFRFNCF DOCUMENTS MAIN IAINED AT FACILE TY Check the appiapnatelovesta describe reference documrntsmmnmined to the facility Nmethatthe <br /> fnat two items on the list I71W be kept at the faint• <br /> 4q0-69b MONITORING PLAN Indicate that this pian is kept ase refermue dus:umem <br /> 49r149c OPERATING MANITAI S 11 OR LL LC'I RONIC EGUIPk4F NT Indicate that Ibis plan is kept w a reference documem <br /> 490-69d CA UST REGULATIONS-Indncme that thesis kept ma reference document <br /> 490469c CA UST 1 AW-Irtdratc that Ibis is kept M a reference ekcurMad <br /> 490.191 SCA'rr WATLR RESOURers CON rROL BOARD(SW RC'B)PURIELATION- "I IAN DBOOK FOR TANK OWNERS-MANUAL AND <br /> ST ATISTICAL INVENTORY RECONC11.to 13 N9-Indicate that this is kept as a miercirc document <br /> 490.69g SWRCB PUBLICATION "UNDERSTANDING AUTOMATIC TANK GAUGING SYS ITMS". Indicate that this is kept as a relenele document <br /> 49669h OTHER-belie ne that other refcrena documents are kept <br /> 490.691 SPFLIFY-11-01THR'is checkd,torero Mtefdocnpkad of the other documemf s)rmrnroriredmthe t'acdiry If addmonnl space is,ceded,ice SeclwnX <br /> 490-70 DESIGNATED OPERATOR TRAINING-Check this luxe maty that this slatem:mv,tar. <br /> 49671 COMMEN'TS/ADDR IONAL INFORMA I ION Make add oxmil comments or you may stied and identify Ore number of additional Pages of mfornauon m descnhc <br /> ane additional UST system momlanng-relied information le g•addnumal inthntahvn tet ed by yon kral xganry 1 Anach any momtoang Ings ihn yuu w,11 M ruing <br /> for me momtrmng or your rank system <br /> 490-72 NAME- Enter the tame of the Peer.who Maundy,conducts the monrtmnng and egmpmmn maintenance under this plan <br /> 490-73 1111.E- Eder the 1n1e of the person <br /> 49674 NAME Fntu the WiM of the srxnnd person.d uppbcallc,who rammely nmduus else mom[onng and eqummem mamieranec abler tars plan <br /> 491,75 TITLE- Enter Ne title of the socand Prison <br /> OWRIOPERATOR SIGNA I URF-1'he tank awneooperalm,facility owitedaperataq or an amhorud representative ofthe owner shall sign m the space I- ded <br /> NE <br /> This signaum ee tit'"than M,signs hehaws that all mformauon submitted is We,accurate,amt complete,died iMt she trnmmg program+pecJid m Sc<uan I X ha, <br /> been implemented <br /> 490-76 RLPRFSE141ING Check the apprapaaic box m raaKame whether the signer R the UST owexaperaam,the UST tevdny awner:uPeraoar'm sit <br /> authorised representausc of the mann <br /> 49()­77 DACE-Fame do,date the plan was stt'nd <br /> 490-78 APPLICANT NAME-Prat or type rfm imirr of he Pelson srgnrng the plan <br /> 490-79 APPI,ICANTTrrLi! I me,the tine of ibe person snenmg the plan <br /> tIPCP UST-D)17fl007)4/4 <br />