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cwdwj T1bpMh14 ,9, id' aPee [I�a►�ewlaoo.eilioi�, 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 OW to installing or modifying monitoring equfpmerL (Note: Numbering of these instructions Follows the data element maintains on the farm.) 4900.5401 MONITORING OF THE UNDER DISPENSER CONTAINMENT Indicate the method used for UDC monitoring, 4WUb.SPP.CIPY-I1`99-0ther^is checked,describe dltr method and If VI-1-I,VI-I-2 or VI-1-3 or VI.1.99 is checked,complete 490.55 to 490-646. 490.55. PANEL MANUFACTURER-EnMr the name oftlw manufacturer of the monimi system=trot 3011101(0011804e) If tMrc is W caarol panel is g,only an 4kcmwl relay boa Or installed)Ionia this space blank. 490-56. MODELif Etrttt the model number for the monitoring system control permit(consob).[f there is ane comm)panel(e.g.,arty an alecmcal relay box is Installed)leave this spate Wank. 490-57 LEAK SENSOR MANUFACTURER Enmrthetamemftipmantffwc of1M eeimWs). 490.59, MODE.4(S)-Brier the model mi nater of the sono(s)implied.Ifad1111onel apace breaded.use Secinn X. 490.49. D6PBCfbN OF A LEAK INTO THE UDC TRIOCIMS AUDIBLE AND VISUAL-ALARMS. Indicate Yo m No 49660, UDC LEAK ALARM TRIGGERS PUMPSHUIDOWN latipm Yaa No 49661. PAILURBIDTSCONNECTION OF UDC MONITORING SYSTEM TRIGGERS AUTOMATIC PUMP SHUTDOWN Indica,Yeo or No 49662. UDC MOMMING STOPS THE FLOW OF PRODUCT AT THE DISPENSRR Iofa,,a Yes a Nu- 490.63. UDC CY KT=CnON IMioete if dro mrotnalion oftho UDC is single-welled,or doublo-welled. 4966401.D"Llf-WA[I,®INIHRSTI l ki,SPACE MONITORING Indicate whet is Used,monitor the ime,emal space. 49044b.LRAK WMUN THE SECONDARY CONTAIMENf OF UDC TRIGGERS AUDIBLE AND VISUAL ALARMS htlka,YescrNo 49665, VII-I ELO TESUING Check the boa ifyou have bow notified by the Stets Weer Resources Control Board(S WRCE)fan the UST(a)move m I by this plan was, _ subliect in Bnhoed Lok Detection ROgdremwa(1 e.,UST has say single-wall component W is located wiaun 1.000 feet of u public drinking osier well). 490-M TESTING OP SBCONDARY CONTAINMRNf COhPOtENT3 EVERY 36 MONTHS (;?ad der box tfym hive secondary oomainment the requires teaung. 49667 SPILL BUCKET TES71NO Check the box ifyou have apo buckets. 4946ga-h.VIE RECORDREEPING.lrsdiean shit monoring and equipment matrdrnalm r rds me italmaiMd for tws fwAltty. 496690 IX TRAINING STATEMENT pock tha box n verity that the etetemem n Imp. REFERENCE DOCUMENTS MAINTAINED AT FACILITY Cheep the gproglelm boxy to describe reRmee doclmiakp mantained I the hoary. More that rhe fire two hams on the lin Mug be"N the facility. 490-96. MONITORING PLAN:Indicate that this plan a kept as a reference document. 496690. OPERATING MANUALS POE ELECTRONIC EQUIPMENT'OdW,the this plan is kept a a reference document 496694. CA UST RIKAILATIONS Indiwe that ttria a kept a s rehmrm dooumont. 490.6%. CA UST LAW Indicate Oft this is kept as a tektwn0 doc a asa- 490-9fSTATE WATER RESOURCES CONTROL BOARD(SWRCB)PUBLICATION "ttANDBOOK FOR TANK OWNERS MANUALAND STATISTICAL INVENTORY RECONCILIATION Idles,fMt this is IoW n e me,reme document. 490698 SWRCS PUBLICATION:"UNDERSTANDING AUTOMATIC TANK CAUOINO SYSTEMS" Indicate Net this is kept as a miscaae document 490496.07HEt Intimae die ognr reRsmce doe mens,ere kept 49D-69i. SPECIFY-If"OTtM"a enacted,ever a brief dmaipl M oftho rebs docmnwt(a)saint-i-d u the fwility.If Mdibonal space is rteeded,ace Seoaon X. 49670. DESIGNATED OPERATOR TRAINING Check ails box to verily that tri etata m a mp. 49671 COMMEN &ADDITIONAL INPORMATION Make addiliOne cotmarw or you may attack and identify,the number of ddttnoel pages of infennodon in describe say additional UST systems nurturing-rde,d information(e,g,additional infomation required by year lace agency). Attach"mortjmnug logs that you will be using fa the monitoring of your milk*Item. 49672. NAME-parer the rame of the poison who muthely conducts the m citono9 and equipment maintenance under this plan. 49673. TITLE Era the tore of the pemon. 49474. NAME-Firer the ores Man second person,if applicable,who routinely conducts the mmrtitonng end eq."mtl mainmum,,under this plat. 49675. TITLE Pate the atle oftM scare person OWNEt/OPERATOR SIONATURE--The tank owner/opersaor,faOBay osrnor/operator,man eWlronzed repleattnetfve ofthc aero elall atgn in the space proved. This sign n,cert fies thin the signor believes that all information submitted Is true,accun,,ad complete,and that the training program specified in Section a IX has 49676. RMIPM TI 0-Check the appropnam box to indicate whetter the signer is the UST Overt r/opentor,the UST facility Dwntt/opemtm,or an Nihmrked representative of the owns. 49677. DATE-Etna she date the plan wit signed. 49679. APPLICANT NAME-Pint or type the nano ofihe person signing the plan. 490.79. APPLICANT TITLE Emir[Fe tido of nc person signing tip plan. J Y UPCF UST-D(12/2007)4/4