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(Agency Use Only) This plan has b K ie ed d: Approved ❑Approved With Conditions Local Agency Sigoal C: Date: Comments or special conditions: ' �- UST Monitoring Plan—Page 2 Instructions Complete a separate UST Monitoring Plan for each UST monitoring 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 12>ior to installing or modifying monitoring equipment (Note: Numbering of these instructions follows the data element numbers on the form.) 490-54a MONITORING OF THE UNDER DISPENSER CONTAINMENT-Indicate the method used for UDC monitoring. 490-54b.SPECIFY-If 99"Other'is checked,describe otter method used. If VI-1-1,VI.1.2 or VI-1-3 or VI-1-99 is checked,complete 490-55 to 490-64b. 490-55. PANEL MANUFACTURER-Enter the name of the manufacnuer of the monitoring system control panel(comic). If there is no control panel(e.g.,only an electrical relay box is installed)leave this space blank. 49046. MODEL g- Enter the model number for the monitoring system conmol 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 came of the mannfacturm of the sensor(s). 490-58. MODEL g(S)-Enter the model number of the sensors)installed.If additional space is needed,me Section X. 49059. DETECTION OF A LEAK INTO THE UDC TRIGGERS AUD®LE AND VISUAL ALARMS. Indicate Yes or No 490-6D. UDC LEAK ALARM TRIGGERS PUMP SHUTDOWN- Indicate Yes or No 490-61. FAILURE/DLSCONNECTON OF UDC MONITORING SYSTEM TRIGGERS AUTOMATIC PUMP SHUTDOWN-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 if the construction of the UDC is single-walled,or double-walled 490-64a DOUBLE-WALLED INTERSTITIAL SPACE MONITORING- Indicate what is used to monism the interstitial space. 490.646.LEAK WITHIN THE SECONDARY CONTAIMENT OF UDC TRIGGERS AUDIBLE AND VISUAL ALARMS-Indicate Yes or No 496-65. VITA ELD TESTING-Cheek the box ifyou have been ratified by the Stam Water Resources Control Board(SWRCB)that the UST(s)covered by this plan is/so: subject to Enhanced Leak Detention Requirements(Le_UST has any single-wall component and is located within 1,000 feet of 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-Check the box if you have spill buckets. 4906ga-h.VIII RECORDKEEPING-Indicate which monitoring and equipment maimenexe records are announced for this facdity. 490-69a IX TRAINING STATEMENT-Check the box to verify that the statement is mu. REFERENCE DOCUMENTS MAINTAINED AT FACILITY-Check the appropriate boxes to describe reference documents maintained at the facility. Note that the fust two nems on the 1¢t ID3t be kept in the facility. 490-69b. MONITORING PLAN:Indicate that this plan is kept as a refinance document. 49069c. OPERATING MANUALS FOR ELECTRONIC EQUIPMENT:Indicate thin this plan is kept as a reference document. 490694. CA UST REGULATIONS-Indicate that this is kept as a reference document. 490-69e. CA UST LAW-Indicate that this is kept as a reference document 490.690 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 490.69g.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 490-69i. SPECIFY-If'X)T ER"is checked,enter a brief description of the other docuumans)maintained at the facility.If additional space is needed,sac Section X. 490.70. DESIGNATED OPERATOR TRAINING-Check this box to verify that this statement is me. 490.71. COMMENTS/ADDITIONAL INFORMATION-Make additional comments or you may attach and identify the number of additional pages of information to describe my additional UST system monitoring-telated information fall,additional information required by your local agency) Attach any monitoring logs that you will be ming for the monitoring of your tank system. 49072. NAME-Enter the name of the person who routinely conducts the monitoring and equipment maintenance under this plan. 490-73. TITLE- Enter the title of the person 490-74. NAME-Enter the name of the second person,if applicable,who rommely conducts the monitoring and equipment maintenance under this plan. 490.75. TITLE- Exner the title of the second person, OWNER/OPERATOR SIGNATURE-The tank owner/operator,facility owner/operator,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,accurate,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 owner/operator,or an authorized representative of the owner. 490.77, DATE-Enter the date the pin was signed. 49078. APPLICANT NAME-Print of type the name ofthe person signing the plan 49079. APPLICANT TILE-Enter the title ofthe person signing the plan UPCF UST-D(12/2W7)4/4