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FL=Al'LAg"� -�_ This plash 6e d nd! ppm,d ❑Approved Wilb Conditionss r Signatures or Special Cooditian Doc UST Monitoring Plan—Page 2 Instructions Complete a s parate UST Monitoring Plan for each UST monitoring system at the facility, This farm must be submitted wiUt your initial UST Operating Pe it Application and within 30 days of changes in the information it contains- Please note that your local agency may require you to obtain .) I prior to installing or modifying monitoring equipment. (Note: Numbering of these instructions follows the data element numbers on Ute Form.) 490-54n.MONITORING OF THE UNDER DISPENSER CONTAINMENT-Indtcae the method used far UDC monitoring, 490-54b.SPEC -If99"Other"is checked,describe otter method used. If VI-I- ,VI-1-2 or VI-1-3 or VI-1.99 is checked,complete 490.55 to 490-64b. 490-55. PANEL MANUFACTURER—EmvThe name of rhe manufadumr ofthe monitoring system control panel(console). If them is no mnwl panel(e.g.,only Be electrical relay ho is insallcd)Icavc this spam block. 490-56- MODE 4- Enter die model number for the monitoring system control pane((console).It there is nu contra]panel(e.g.,only an electrical relay box is installed)leave this space b) Ek. 490-57. LEAKS NSOR MANUFACTURER—Enter the name Of tile naaufoourar of the sensor(s). 490.58. MODEL (S)—Enter the mode(number of the sensur(s)installed.If additional spuce is needed,use Section X. 490.59- DETEC ON OF A LEAK INTO THE UDC TRIGGERS AUDIBLE AND VISUAL ALARMS. Indicate Yes or No 49040. UDC LE K ALARM TRIGGERS PUMP SHUTDOWN- Indicate Yes or No 490.61. FAILUR /DISCONNECTION OF UDC MONITORING SYSTEM TRIGGERS AUTOMATIC PUMP SHUTDOWN-Indicate Yes or No 490-62. UDC ME ITORING STOPS TI IE FLOW OF PRODUCT AT THE DISPENSER-Indicate Yes or Na. 490-63, UDC CO STRUCfiON- Indicate if the Construction of the UDC is single-walled,or double-walled. 490-649.DOUBL -WALLED INTERSTITIAL SPACE MONITORING- Indian rc what is used la monimnhe inmrstitiol space 490-641r.LEAK t II TES THE SECONDARY CO you have been OF UDC TRIGGERS AUDIBLE AND VISUAL ALARMS•Indicate Yes or No 490-65. VII-1 t TESTING-Cheek rite dos ifyau have bon notified by the State]Vater Resources Control Board(SWRCB)flint the OST(s)Covered by this plan is/arc subject Enhanced Leak Detection Requirements(i.e.,UST hos any single-wall component and is Incited within 1,000 feet Ofa public drinking water well 1. • 490-6G. TEST[[ OF SECONDARY CONTAINMENT COMPONENTS EVERY 36 MONTHS-Check the box il'yau have secondary containment dot requires testing. 490.67. SPILL B CKET TESTING-Cheek the box if van have spill buckets. 490.6tla4i.Vlll It ORllKEEPING-indicate which monitoring and equipment maintenance retards are maintained for this Identity. 490-69n IX TRA C STATEMENT•Check the box to verify taloa die statement is true. REFER CE DOCUMENTS MAINTAINED AT FACILITY—Check the appropriate boxes to describe reference dacuments maintained at the facility. Note that the rst ova ems on the list must be kept at die facility. 490-69b. fi MONIT(RING PLAN:Indicate that this plot)is kept as it reference dors neat. 490-69c. OPEPAI ING MANUALS FOR ELECTRONIC EQUIPMENT:Indicate that this plan is kept us u refacnce document. 490.69R CA UST tEGULATIONS-Indicate that this is kept as a reference document. 490-699. CA UST AW-Indicate that this is kept as a reference document. 490.69E STATE 1 ATER RESOURCES CONTROL BOARD(SWRCB)PUBLICATION- "HANDBOOK FOR TANK OWNER STATIS ICAL INVENTORY RECONCILIATION-Indicate that this is kept ns a reference document. S-MANUAL AND 490-69g,SWRCE UBLICATION:"UNDERSTANDING AUTOMATIC TANK GAUGING SYSTEMS":Indicate that this is kept its n reference document. 41X1-G9h.OTHER- dieme that other referencedocuments arc kept. 490.69:. SPECIFY-f D OPERATOR dtecked,emera brief description afthe olterdocument(s)maintained at the facility,Iradditional space is needr:d,see Section X- 490-711. DESIGNA ED DDITIO A 7RAINING-Check ads box to verify that alis statement is we. 490-71. COMME 5/ADDITIONAL INFORMATION—Make additional comments or you may attach and identity The number of additional Pages of information to describe any addita at UST system mommring-re rued immolation(e.g.,additional information required by your local agency). Attach any monitoring lags that you will be using for the mon taring of your milk system. 490-72. NAME—E mer the Dome of the person who routinely conducts the monitoring and equipment maintenance under this plan, 490.73. TITLE- mer the tide of the person. 490.74. NAME—E Cott de name ofth second person,if applicable,who routinely conducts the monitoring and equipment maintenance ander this plat. 490-75. TITLE- En r rhe title of the second person. 0""w O ERATOR SIGNATURE—Tale took otvner/openuaq facility owner/opermor,or mi authorized representative of the owner shot]sign in the space provided. This signal cenific9 that die sigucrbelicves that all information subnmilted is true,accurate,mid complete,nnd alul 1119 tminingprogmm specified in Section IX has been implemented. 490-76. REPRESEN ING—Check the appropriate box m indicate whether the signer is the UST Owner/operator,the UST facility awner/opemtoy or on auaarized iamsentulivc of die owner, 490-77. DATE—En r the date am plan was signed. 4911-78. APPLICAN NAME—print or type the rmmc of lbe person signing the plan. 490-79. APPLICA TITLE—Enter to title of ale person signing the pWn. UPCF UST-D(12/2017)414