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(Agency Use 0-11) This plan has been reviewed and: ❑Approved ❑Approved With Conditions Local Agency Signature' . Comments or Specal ConWhons. —Date' UST Monitoring Plan—Page 2 Instructions Complete a separate UST Monitoring Plan for each UST ramimring 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 prior to installing or modifying monitoring equipment (Note: Numbering of Nese instructions follows the data element numbers on the form.) 490-54a.MONITORING OF THE TINDER DISPENSER CONTAINMENT-Indicate the method used for DOC monitoring. 490.54b.SPECIFY-If 99-'Other'is checked,describe other methad used If VI-1-1,VI-1-2 or Vl-I-3 or VT-1-99 is checked,complete 490.55 to 490-64b. 490.55. PANEL MANUFACTURER-Emer the time of Ne manufachuer of the maintaining system control panel(console). If Were ism control panel(e.g.,only an electrical relay box is installed)leave this space blank. 490-56. MODEL 8- Enter We model number for the monitoring system control Panel(console).if there is an control parol(e.g.,only an electrical relay box is installed)leave this space blank. 490.57. LEAK SENSOR MANUFACTURER-Enter the carne ofthe manufacturer of"sensors). 490.58. MODEL N(S)-Enter the model number of the sensors)installed.If additional space is needed,us:Section X. 490-59, DETECTION OF A LEAK INTO THE UDC TRIGGERS AUDIBLE AND VISUAL ALARMS. Indicate Yes M No 490.60. UDC LEAK ALARM TIUGGERS PUMP SHUTDOWN- Indicate Yes or No 490-61. FAILURPIDISCONNECTION OF UDC MONITORING SYSTEM TRiOGERS A[TI'OMATTC PUMP SHIIfDOWN-In ionic 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 construction oftbe UDC is single-walled,or double-walled. 490.64s.DOUBLE-WALLED INTERSTITIAL SPACE MONITORING- Indicate what is used to monitor the interstitial space. 490646.LEAK WITHIN THE SECONDARY CONTAIMENT OF UDC TRIGGERS AUDIBLE AND VISUAL ALARMS-Indicate Yes or No 49065. VII-1 ELD TESTING-Check the box ifyou have been ratified by the State Water Resources Control Board(SWRCB)that the UST(s)covered by dus plan is/are subjeet to Enhanced Leak Detection Requirements lie,UST has any single-wall component and is located within 1,000 feet of a public drinking water well). 49066. TESTING OF SECONDARY CONTAINMENT COMPONENTS EVERY 36 MONTHS-Chock the box ifyou have secondary containment that requires testing. 490-67. SPILL BUCKET TESTING-Check the box ifyou have spill buckets. 49068a-h VIII RECORDKEEPING-Indicate which monitoring and equipment maintenance 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 eppmpmme boxes to describe reference documents maintained at the facility. No¢that the fico two items on the list mad be kept at the facility. 49069b. MONITORING PLAN:Indicate that this plan is kept as a reference document. 49069c. OPERATING MANUALS FOR ELECTRONIC EQUIPMENT,Indicate that this Plan is kept as a reference document 490669d. CA UST REGULATIONS-Indicate that this is kept as a reference document. 49069e. CA UST LAW Indicate that this is kept as a reference document 490-69C STATE WATER RESOURCES CONTROL BOARD(SWRCB)PUBLICATION- "HANDBOOK FOR TANK OWNERS-MANUAL AND STATISTICAL INVENTORY RECONCILIATION-Indicate that this is kept as a ref men a document. 49069g.SWRCB PUBLICATION:"UNDERSTANDING AUTOMATIC TANK GAUGING SYSTEMS":indicate that this is kept as a note.document. 490691,OTHER-Indicate that other reference documents are kept. 49069i. SPECIFY-If"OTHER"is checked,enter a brief description of the other document(s)maintained at the facility.If additional space is needed,see Section X. 490-70. DESIGNATED OPERATOR TRAINING-Check this box to verify that this statement is tnse. 490-71. COMMENTS/ADDITIONAL INFORMATION-Make additional comments or you may attach and identify the number of additional pages of information m describe any additional UST system monitoring-related information log.,additional informant,required by your local agency). Attmh any mocimring legs that you will be using for the monitoring ofyour tank system. 490-72. NAME-Enter the muse of the person who routinely conduct the monitoring and equipment maintenance under ons plan. 490673. TITLE- Enter the title of the person. 490.74. NAME-Enter the muse of the second person,if applicable,who routinely conducts the monitoring and equipment maintenance,under this plan. 490.75. TITLE- Enter the nae of the second person. OWNERIOPERATOR SIGNATURE-The tank owner/operator,facility owner/openlor,or an authorized representative of the owner shall sign in the space provided. This signature certifies that the signer believes that all information submitted is true,acct ale,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 owner/operator,the UST facility owmr/opemlor,or an authorized representative of the owner. 490-77. DATE-Enter the dale the plan was signed. 490-78. APPLICANT NAME-Print or type the muse of the person signing the plan 490-79. APPLICANT TITLE-Enter the tide of the person signing the plan UPCF UST-D(12/2007)4/4