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[Ills Plan 11.1i been r-,.wt%cd p,l ppr,,t cd ❑Approt cd W III C dill 1i Local AlenSi_ Commentsor.Srecial C., Date UST 'Monitoring Plan e 2 Instructions 1:5 Page CoMPICIC a separate UST -Monitoring Plan for each UST monitoring, system at the facilit%. i f Must be submitted %vith %our initial UST chanes in the information it contains' Please note that )our local agenc% require %ou to Operating Permit Application and within 30 days of chan, This orm obtain approval tion to install' [lie font,.) in2orniodiAins nionitoringequipillent. (Note: Numbering oftlieseinstruclio Its Follo%%S the data element fimte,5 on 490-54a M0,14TORING OF THE UNDER DISPENSER CONTAINMENT,Indic-lie the nieffied used for LDC monitoring 490-54b SPECIFY-If 9901flef"s checked.describe Other method used ITVI-1-1.VI-1-2 or VI-1-3 or VI-1-99 a checked COIIIPIC[0490-55to490-64b 490-55 PANELMANUFACTUREREnter 1herianicaftite manufacturer afthe monitoring system control panel lconsole) relay box is installed)leave this space blank If[here is no control panel.c •On,% an clectricaj 490-56. MODEL Enter the model number for the monitoring A stem control panel i conjoin) If there is no control panel it I,,ollly all decirical relay box is installed,It.,e this space blank. 490-51 LEAK SENSOR MANUFACTURER-Enter the nameor( ofille man tu 490-58 MODEL (Si m -Enter the odel number Of1he senssl installed I Uric lel'Ofthe se sor(si. J90-59 DE7 ECTION OF A LEAK IN f additional space n is needed.use Section X TO THE UDC TRIGGERS AUDIBLE AND VISUAL ALARMS Indicate yesorNo 490-60 UDC LEAK ALARM TRIGGERS PUMP SHUTDOWN- Indicate Yes or No 490-61 FAIL(JR&DISCONNECTION OF UDC MONITORING SYSTEM TRIGGERS AL70.\,IATIC PLMP SHLTDOW.14-Indicate Yes or No 490-62 UDC MONITORING STOPS THE FLOW OF PRODUCT AT THE DISPENSER-Indicate Yes or No 490-63 UDC CONSTRUCTION- Indicate iffhe construction of the UDC is jingle-wailed.ordouble-walled 490-64a DOUBLE-WALLED INTERSTITIAL SPACE MONITORING- Indicate what is used to munitor the interstitial space 490-64b LEAK WITHIN THE SECONDARY CONTAINIENT OF UDC TRIGGERS AUDIBLE AND VISUAL ALAILMS;-Indicate Yes or No 490-63 V11-I ELD TESTING-Check the box ifyou have been notified by the Slate Water Resources Control Board(M."ICB)that the UST(s)covered by this plan is,are subject to Enhanced Leak Detection Requirements(i UST has any single-wall component and is located within 1,000 490-66 TESTING OF SECONDARY CONTAINMENT COMPONENTS EVERY 36 NJONDIS fee,ofa public drinkingwater w 490 Check the box Ifcow hi%t second ell 490-67 SPILL BUCKET TESTING-Check the box ifyou have spill buckets -containment that requires lesuilL. -68a-h.Vill RECORDKEEPING-indicate which monitoring and equipment maintenance records are rnainiameJ for this f ill, 490-69a IX TRAINING STATENIENT-Check the box to verify that the statement is true ac REFERENCE DOCUMENTS.%,WNTAINED AT FACILITY-Check the appropriate boxes to describe reference documents maintained at the facility Note that the first neo items an the list must be kept at the faciliry 490-69b IMONITORING PLAN-Indicate that this plan is kept as a reference document 490-69c OPERATING MANUALS FOR ELECTRONIC EQUIPNIENT Indicate that this plan is kept as a reference document 490-69d CA LIST REGULATIONS-Indicate that this is kept as a reference document 490-69c. CA UST LAW-Indicate that this is kept as a reference document. 490.69f STATE WATER RESOURCES COINTROI.BOARD(SWRCB)PUBLICATION- -HANDBOOK FOR TANK OWNERS fA'%UAI-AND STATISTICAL INVENTOR)'RECONCILIATION-Indicate that this is kept as a reference doc 490-69g SWRCB PUBLICATION "UNDERSTANDINGAUTONIATIC TANK GAUGING document 490-69h OTHER-Indicate that other reference documents are kept SYSTEMS' Indicate that this is kept as a reference document 490-69i SPECIFY-If"OTHER-is checked.enter a brief description of the Other documents;)maintained at the facilliv Ifacklmonal space is needed.see Section X 490-70 DESIGNATED OPERATOR TRAINING-Check this box to verify that this statcriteril is Inle 490-71 COMMENTS,ADDITIONAL INFORMATION- Make additional comments or call MA,attach and identify the number ofadd-Illonal pages"fullbrMation to describe any additional UST sYsicin monnormil-relatted information(e.g.additional information * for the monitoring of%our tank s%stcm required by%our local agdMN I Attach any monitoring logs that Yon ttill be using 490-72 NAME-Enter the name Of the Person who rounneiv conducts the monitoring and me 490-73 TITLE- Enter the title of the person vqulpincnt maintenance under this plan 490-74 .14,JL%fE-Enter the name Of the second Person if applicable.who roulintiv conducts the Monitoring and equipment maintenance under this plan 490-75 TITLE- Enter the title of the second person OWNER OPERATOR SIGNATURE-The tank Owner operator.facility owner operator,or an authorized rcprescruallve orlhe a%,ncl shall This signature certifies that the signer believcs that all information subi' ill;n in'lit'Pace prodded been implemented nlItcd Is true accurate.and climplele and that the training MUM=specified in Section IX has 440-16 REPRESENTING--Check the appropriate box to indicate%thether the il-eller is[tic LST owner operator he L 5 r laclin,Owner operator or in authorized represemaine of the Owner 190--7 DATE -Enter the date the plan was signed 490-71 APPLWAN7NAME -Print jfl)pcthe name ol'(h;:person signore the plan 490-'79 APPLICANT TITLE-Enter the tide ol"the person signing the plan UPCFtSI'-Li(I2