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(Agency Use Only) :Thisplan"bmye ewedand: J,ppproved [IveApprod With Conditions— Local Agency Signature: Date: 5��Comments or Special Cos: UST Monitoring Plan — Page 2 Instructions Complete a separate UST Monitoring Plan for each UST monitoring system at the facility. This form mast be submitted with your initial UST Operating Permit Application and within 30 days of changes in the information it contains. Please note that you 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 490-64b. 490-55. PANEL MANUFACTURER -Enter the name ofthe nanufacmrer ofthe monitoring system control panel (console). Ifthere 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 camrol 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 ofdc sensor(s). 490-58. MODEL #(S) - Enter the model number ofthe se tuar(s) installed Ifadditional space is needed, use Section X. 490-59. DETECITON OF A LEAK INTO THE UDC TRIGGERS AUDIBLE AND VISUAL ALARMS. Indicate Yes or No 490-60. UDC LEAK ALARM TRIGGERS PUMP SHUTDOWN- Indicate Yes or No 490-61, FAMURE/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. 49063. UDC CONSTRUCTION - Indicate if the connotation ofthe UDC is single -walled, or double -walled 49064a DOUBLE -WALLED INTERSTITIAL SPACE MONITORING - Indicate what is used to monitor the interstitial space. 490-64b. LEAK WITHIN THE SECONDARY CONTAMIENT OF UDC TRIGGERS AUDIBLE AND VISUAL ALARMS - Indicate Yes or No 490-65. VII -I ELD TESTING -Cheek the box ifyou have been notified by the State Water Resources Control Board (SWRCB) that the UST(s) covered by this plan is/an: subject to Enhanced Leak Detection Requirements (i.e., UST has any single-wall component and is located within 1,000 feet ofa public drinking water well). 490-66. TESTING OF SECONDARY CONTAINMENT COMPONENTS EVERY 36 MONTHS - Check the box ifyou have secondary, containment that requires testing. 490-67. SPILL BUCKET TESTING - Check the box ifyou have spill buckets. 490.6ga-h. WIT RECORDKEEPING -Indicate which monitoring and equipment maimemnce records are 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 fust two items cm the list must be kept at the facility. 49069b. MONITORING PLAN: Indicate that this plan is kept as a reference ducumcnn 49069c. OPERATING MANUALS FOR ELECTRONIC EQUIPMENT: Moak that this plan is kept as a reference document. 490-69d. CA UST REGULATIONS - Indicate thin this is kept as a reference document. 490-69e. CA UST LAW - Indicate that this is kept as a reference document 490-69£ STATE WATER RESOURCES CONTROL BOARD (SWRCB) PUBLICATION - "HANDBOOK FOR TANK OWNERS - MANUAL AND STATISTICAL INVENTORY RECONCILIATION - Indicate thin this is kept as a reference documom 49069g. SWRCB PUBLICATION: "UNDERSTANDING AUTOMATIC TANK GAUGING SYSTEMS": Indicate that this is kept as a reference document 490-69h. OTHER - Indicate that other reference docun ear are kept 490-69i. SPECIFY-If"OTHER" is checked, enter a briefdescription of the other document(s) maintained at the facility. If additional space is needed, see Section X 4907a DESIGNATED OPERATOR TRAINING - Check this box to verify that this statemet, is true. 490-71. COMMENTS/ADDITIONAL INFORMATION -Make additional comments myou may attach and identify the number ofadditional pages of infomuuion to describe any additional UST system monitoring -related information (e.g.. additional information required by your local agency). Attach arty monitoring logs that you will be wing for the maintaining ofyour took system 490-72. NAME- Enter the name ofthe person who routinely conducts the monitoring and equipment maintenance under this plan 490-73. TITLE - Enter the tine ofthe person 49044. NAME- Enter the name ofthe second person ifappliable, 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 ownenYoperato; facility owner/operator, or an am ianzed representative of the owner shall sign in the space provided. This signature des oat the signer believes that all information submitted is mise, accurate, and complete, and that the training program specified in Section IX has been implemented. 49076. 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- emu the dine 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 E UPCF UST -D (12/2007) 4/4