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(Agency Use Only) This plan h been revnewe, [Approved i]Approved With Correlate 7 Local Agency Signature: Dale'... .� Comments or Special Conditions: kc ✓PAµ,1 `ItY4A( ls„y"`v,a UST Monitoring Plan—Page 2 Instructions Complete a separate UST Monitoring Plan for each UST monitoring system at the facility. This form must he 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 these instructions follows the data element numbers on the form.) 49054a MONITORING OF THE UNDER DISPENSER CONTAINMENT-Indicate the method used for UDC monitoring. 490-546.SPE.CIFYdf 99"Ones"is checked describe other method used. If VI-I-1,VI.1.2 or VF1-3 or VId-99 is checked,complete 490.55 to 490.646. 490-55. PANEL MANUFACTURER—Encu the name ofthe manufacturer ofthe monitoring system control panel(console). If there is no control panel(e.g.,only an electrical relay box is installed)leave this space blank. 490-56. MODEL 8- Ener the model number for the monitoring system control panel(console).If there is no control panel(e.g.,only an electrical relay box is installed)leave this space blank. 490-57. LEAK SENSOR MANUFACTURER—Enter the name of the manufachaer of the sensays) 490.58. MODEL N(S)—Enter the model number of the sensm(s)installed.If additional space is needed,use Section X 490-59. DETEC ION OF A LEAK INTO THE UDC TRIGGERS AUDIBLE AND VISUAL ALARMS. Indicate Yes or No 49060. UDC LEAK ALARM TRIGGERS PUMP SHUTDOWN- Indicate Yes or No 49061. FAILUREMISCONNECTION OF UDC MONITORING SYSTEM TRIGGERS AUTOMATIC PUMP SHUTDOWN-Indicate Yes or No 490-662. UDC MONITORING STOPS THE FLOW OF PRODUCT AT THE DISPENSER-Indicate Yes or No. 490-63. UDC CONSTRUCTION- Indicate if the construction ofthe UDC is single-walled or double-walled. 490-&a.DOUBLE-WALLED INTERSTITIAL SPACE MONITORING- Indicate what is used to monitor the interstitial space. 490-64b.LEAK WITHIN THE SECONDARY CONTA]MENT OF UDC TRIGGERS AUDIBLE AND VISUAL ALARMS-Indicate Yes or No 490.65, VI-1 ELD TESTING-Cheek the box ifyou have been notified by the State Water Resources Control Board(SWRCB)that the UST(s)covered by this plan is/me subject to Enhanced Leak Detection Requirements(i.e.,UST has any singlo-wall component and is located within 1,000 feet ofa public drinking water well). 49066. TESTING OF SECONDARY CONTAINMENT COMPONENTS EVERY 36 MONTHS-Check the box ifyou have secondary containment that requires testing 490-67. SPILL BUCKET TESTING-Cheek the box ifyou have spill buckets. 49068a-h.VII RECORDKEEPING-Indicate which monitoring and equipment maintenance records are maintained for this facility. 49069a IX TRAINING STATEMENT-Check the box to verify that the statement is we. REFERENCE DOCUMENTS MAINTAINED AT FACILITY—Check the appropriate boxes to describe reference documents maintained a the facility. Note that the first two items on the list M=he kept at the facility. 490-69b. 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 490-69d CA UST REGULATIONS-Indicate that this is kept as a reference document 490-69e. CA UST LAW-Indicate shot this is kept as a reference document 490-W STATE WATER RESOURCES CONTROL BOARD(SWRCB)PUBLICATION- `HANDBOOK FOR TANK OWNERS-MANUAL AND STATISTICAL INVENTORY RECONCILIATION-Indicate that this is kept as a reference document 490-698 SWRCB PUBLICATION:"UNDERSTANDING AUTOMATIC TANK GAUGING SYSTEMS":Indicate that this is kept as a reference document 490-69h.OTHER-Indicate that other reference documents are kept- 490-691i. ept490-69i. SPECI'Y.If"OTHER"is checked,enter a brief description ofthe other document(s)maintained at the facility.If additional space is needed,sce Section X. 490.70. DESIGNATED OPERATOR TRAINING-Check this box to verify that this statement is we. 490-71. COMMENTVADDMONAL INFORMATION—Make additional comments or you may attach and identify the number ofadditional pages ofinfomnation to describe arty additional UST system monitoring-related information(e.g.,additional information required by your local agency). Attach any monitoring logs that you will be using for the monitoring ofyour tank system. 49072. NAME—Enter the name ofthe person who routinely conducts the monitoring and equipment maintenance under this plan. 49073. TITLE- Enter the title ofthe person. 490-74. NAME—Enter the name ofthe second person,if applicable,who routinely conducts the monitoring and equipment maintenance under this plan. 490-75. TITLE- Enter the title ofthe second person. OWNER/OPERATOR SIGNATURE—The tank owner/opamor,facility owner/operator,or an authorized representative ofthe owner shall sign in the space provided. This signature certifies that the signer believes that all information submitted is true,accurate.and complete,and that the training program specified in Section IX has been implemented 49076. REPRESENTING—Check the appropriate box to indicate whether the signer is the UST owncdoperator,the UST facility owner/operator,or an authorized representative ofthe owner. 49077. DATE—Enter the date the plan was signed. 490-78. APPLICANT NAME—Print or type the time ofthe person signing the plan. 49079. APPLICANT TITLE—Enter the title ofthe person signing the plan. UPCF UST-D(12/2007)4/4