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(Agestey Ude Only) Thispim eviewed Approved With Conditions ,
<br /> Local Agency Signature. / Dam, t/
<br /> Comments or Special Con i n8: _..�.._.
<br /> UST Monitoring Plan—Page 2 Instructions
<br /> Complete a separate UST Monitoring Plan for each UST monitoring system at the facility. This form must be submitted with your initial UST
<br /> Operating Permit Application and within 30 days of changes ut 0le information it contains- Please: note that your local agency may require you to
<br /> obtain approval prigs to installing or modifying monitoring equipment. (Note; Numbering of these instructions follows the data element numbers on
<br /> the form.)
<br /> 490.54&MONITORING OF THE UNDER DISPENSER CONTAINMENT-Indican,the matbod used for UDC monitoring.
<br /> 490.546.SPECIFY-if W"(aha"is checked,describe other method used
<br /> If VI-1.1,10I-1-2 or Vl-1.3 or VI-1-99 is checked,complete 490.55 In 490-64b.
<br /> 490.55. PANEL MANUFACTURER-Enter the tame of the manufacturer of the monitoring system control lease,(conaok). If there is no control panel(e.g.,only an electrical
<br /> uslay box is memtled)leave this space blank.
<br /> 490-M. this If- Enter the model number ton the manito Ing tysr<m corarol panel(00nsole).if there is no comrol Pone'("81.only an elatrical relay box is immlled)In"
<br /> space blank.
<br /> 490-57. LEAK SENSOR MANUFAC lIURER-Enterthe stone of the ma mfix,,uW of the srntm(s).
<br /> 49658. MODEL 4(S)-Etter the model number of fhe anaor(e)instilled If additiornel aPce is needed,O9a Section x
<br /> 490-% DETECTION OF A LEAK INTO THE UDC TRJf3OERS AUDIBLE AND VISUAL ALcoded, e S ctio Yes or No
<br /> 490.60. UDC LEAK ALARM TRIGGERS FUME$HU IGGER- UDIBLEndicate A or No
<br /> 490.61. FAIUDC MONITORING
<br /> NITO I NNECTIUN GP UDC MONITORING SYSTEM TRIGGERS AUTOMATIC PUMP SHUTDOWN-Indicate Yes or No
<br /> 49062. UDC C O CONSTRUCTION
<br /> STOPS THE FLOW OF PRODUCT AT THE DISPENSER-lndieess Yes or No.
<br /> 490.63. UDC CONSTRUCTION- Indiratt,lithe construction of the UDC is single•waikd,or double-welled
<br /> 49064a DOUBLE.WALLED MMSTTrtAL SPACE MONITORING- Indie&te what is,reds to monitor the interstitial spa,,
<br /> 490.646.LEAK WITHIN Tlie SECONDARY CONTAIMENT OF UDC TRIGGERS AUDIBLE AND VISUAL ALARMS-Indian,yes or No
<br /> 49065, sublets 10 Enhanotal Lnk Detection VITA ELD TESTING-Check the box if you have been notified by the Stan,Water Resources Control Board IS WRCB)dent the UST(s)covered by this pian is/arc
<br /> 490.66. TESTING OF SECONDARY CONTRequirementsAIINMENT COMPONENTSe..UST has any ERY Swell m THS- and i9 le box i within 1,000 fuA of a public drinking warm,.ell).
<br /> 49067. SPILL BUCKET TESTING-Check the box if you havesoll etVERY 36 MONTHS-Cheek the box if you have secondary umlt&inment the,requires testing.
<br /> 490-6' "VIII RECORDKEUMG-Indimm which monitoring and equipment meimm�atrce records era maintained for this facility.
<br /> 4 -
<br /> 9069a IX TRAINING STATEMENT-Check the box to verify that the ngtammt i5 Inle.
<br /> REFERENCE DOCUMENTS MAINTAINED AT FACILITY-Check the appropriate boxes to taenia mlemna documents mainmined r the facility, Nom that the
<br /> first two hams an the list MMbe kept at the terohty.
<br /> 490.696. MONITORING PLAN,Indicate the,this pian is kept as a reference doxi main
<br /> 490-69cOPERATING MANUALS FOR ELECTRONIC EQUIPMENT.lodicme dust this plan is kept ss a reference dowment.
<br /> 490.694 CA UST REGULATIONS-lin icem that this D kept as a reference document
<br /> 490-69e. CA UST LAW-Indiana thin this is kept as a relemose document
<br /> 490-69f,STATE WATER RESOURCES CONTROL 80ARD(S WRCB)PUBLICATION- "HANDBOOK FOR TANK OWNERS-MANUAL AND
<br /> STATISTICAL.INVENTORY RECONCILIATION-Indicate ON this is kept as a reference document
<br /> 49669¢.SWRCB PUBLICATION:"UNDERSTANDING AUTOMATIC TANK GAUGING SYSTEMS":Indicate than this is kept as a remrence d"isnenr,
<br /> 490.691L OTHER-Indicate that Otho-i,teo,,c documents ere kept.
<br /> 49069:. DESIGSPFCrNATED
<br /> OPERA s shacked,enter s brief description o vee othm dos Statement is tairhed at the facility.I(additinow sped i9 needed,see SMhon X.
<br /> 490.70. DESIGNATED OPERATOR TRAINING-Check this box to ven(y,then this steWnrnt is(ve.
<br /> 49671, C�nfv(p4tional EN MADD�[�ton NFORMATION-Make additional comments or you may Rasa and identify the number of additional pages of information m Msnn6e
<br /> for me on-wwoug ofyo Your tank system rdus�inl6rmatipn(e.g.,additrtW information required by Yom local eganey). Attach any NAME-Enter monluxing Ings Ihet You will h using
<br /> 9672. ner the mime of she person who rominety
<br /> 49673. TITLE- Ener the title of the Person, moduois she monitoring and equipment maousterce under this plan.
<br /> 49674. NAME-Eater the nems of the omaad poison,
<br /> 490.75. TITLE- Eater the rite of(ire second person. if applicabta,cath
<br /> lm routinely Wndugy e monitoring and equipmem meig,,mu ce under this plan
<br /> OWNER/OPERAOR SIGNATURE-
<br /> acility
<br /> This gnamm Certiifies dear the aigem belie e9 thetoal (or�jn ov submitted hg /true,etxourate,and won Ism nrative of me owner shall sign in the space provided
<br /> been implemented. hap and that the(mining program specified in Section lX has
<br /> 490.76. REPRESENTING-Chea the ovmrr.appatiphem box to and
<br /> whether the signer is the UST owner/operator,the UST facility owner/operator,or an
<br /> authorized telsesematrve of We owner.
<br /> 49D77. DATE--Inter the dust,the pias svq signed.
<br /> 49678. APPLICANT NAME-Rini pr type the name of the pmsos signing the plan,
<br /> 49679. APPLICANT TITLE-Enter the ritle of the person signing the plan.
<br /> UPCF UST-D(122007)4/4
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