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Llsenry U11 000 This plan has be<n mJfCv land: pproved E)Approved With undoumn Local Aper}Jit, joule. Date. I Comments r Special Condioi s'. � I UST Monitoring Plan—Page,2 Instructions Complete a separate UST Monitoring Plan for each UST monitoring system at the facility. This form most 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 approvalro for 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 UDCmonitoring. 490-54b.SPECIFY-If 99"Other'.is checked,describe other method used. If V1.1.1,VI-1-2 or VI-1-3 or VI-I-99 is checked,complete 490.55 to 490-64b. 490-55. PANEL MANUFACTURER-Enter the name of the numanueturer of the monitoring system Control panel(console). If there is account panel m g-.only an electrical relay box is installed)leave this space blank. 490-56. MODEL k- Enter the model number for the monitoring system cannot panel(console).If there is no control panel(cg.,only an electrical relay box is installed)leave this space blank. 490.57 LEAK SENSOR MANUFACTURER-Enter the name of themanufenner ofthe..a,($), 490.58. MODEL M(S)-Enter the model number of the screams)installed.Ifedditianal space is needed,use Section X. 490-59. DETECTION OF A LEAK INTO THE UDC TRIGGERS AUDIBLE AND VISUAL ALARMS. Indicate Yes or No 49040. DOC LEAK ALARM TRIGGERS,PUMP SHUTDOWN- Indicate Yesor No '., 490fi 1, FAILURE/DISCONNECTION OF UDC MONITORING SYSTEM TRIGGERS AUTOMATIC PUMP SHV(DOWN-Indicate Yes of No 49M2. UDC MONITORING STOPS THE FLOW OF PRODUCT AT THE DISPENSER-Indlside Yes or No.- 49M3. UDC CONSTRUCTION- ItdiwR if the cettstrnction ofthe UDC is single-walled,or double walled. 490-64a.DOUBLE-WALLED INTERSTITIAL SPACE MONITORING- Indicate what is used to monitor the munatitial space. 490.646.LEAK WITHIN THE SECONDARY CONTAIMENT OF GDC TRIGGERS AUDIBLE AND VISUAL ALARMS-Indicate Yes or No 490-65. VII-I ELD TESTING-Check the box ifyou have been replied by the Stat Water Resources Control Board(SWRCB)that the UST(s)covered by this plan isiare subject to Enhanced Leak Detection Requimments(i.e.,UST has any singlo-wdl comp went and is locatn ed within 1,000 finer.public drinkins water well). 490-66. TESTING OF SECONDARY CONTAINMENT COMPONENTS EVERY 36 MONTHS-Check the box ifyon have secondary concurnment that requires testing. 490.67. SPILL BUCKET TESTING-Check the box ifyon have spill buckets. 490-68a-h.V I ll RECORDKEEPING-Indicate which monitoring and equipment maintenance records am maintained for this facility. W' 490-69. IX TRAINING STATEMENT-.Check the box to verify that the statement is one. REFERENCE DOCUMENTS MAINTAINED AT FACILITY-Check the appropriate boxes to describe reference documents mammined at the facility. Note that thc find two items on the list al"be kept at the facility. 490-69b. MONITORING PLAN:Indicate that this plan is kept as a reference document. 490-69c. OPERATING MANUALS FOR ELECTRONIC EQUIPMENT:Indicate tial this plan is kept u a reference document. 490-69d. CA USE REGULATIONS-Indicate that this is kept as a reference document. 490-69e. CA USE 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 that this is kept as a reference documem. 490-69g.SWRCB PUBLICATION:"UNDERSTANDING AUTOMATIC TANK GAUGING SYSTEMS":Indicate that this is kept to a reference document. 490.69h.OTHER-Indicate that other mfemncc documents are kept. 491469i. SPECIFY-If'-OTHER"is checkeQ enter a briefelescription of the other documents)maintained at the facility,Ifischhoonal space is needed,we Section X. 490.70. DESIGNATED OPERATOR TRAINING-Check this box to verify that this statement is true. 490.7L COMMENTS/ADDITIONAL INFORMATION-Make additional comments or you may attach and idendfy the number of additional pages of infomotion to describe any additional UST system monitoring-related information m.s.additional information required by your local agency). Attach any monitoring logs that you will be swing far the momilming of yam tank system. 490-72. NAME-Enter the alone ofthe person who routinely conducrs the monitoring and equipment maintenance miler this plan. 490.73, TITLE- Enter the title ofthe person. 490-74. NAME-Enter the name ofthe second person,ifapplicabte,who routinely conducts the monitoring and equipment mamtnance under this plan. 490.75. TITLE- Enter the tide ofthe second person. OWNERIOPERATOR SIGNATURE-The tank owner/operator,facility owner/opemmr,or an authorized representative ofthe owner shall sign in the space provided. This signature certifies that the super believes that all information submitted is one,=come,and complete,and that the training program specified in Section IX has been implemented. 490.76. REPRESENTING--Check the appropriate box to indicate whether the signer is the UST ownermperamr,the USE facility owner/operator,or an authorized representative of the owner. 490-77. DATE-Enter the date the plan was signed. 490-78. APPLICANT NAME-Print or type the name ofthe person signing the plan. 490-09. APPLICANT TITLE-Eater the tide ofthe person signing the plan. W" VPCF UST-D(12/2007)4/4