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(Agency We Only) This plan has been Levi and: !pPPmved (�,flpproved With C Ma%itiiooy ns Local Agency Signam.'' _ ✓ Date: -.Ir �o/L n Comments or Specir�mons: A w � . t �m ail , /' � � f/ _ f U5T 7S /� Iri�'.'r " f,4.31 ( fHV.ry . 'enJ (/ ne6l,,fl, N 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 mior to installing or modifying monitoring equipment. (Note: Numbering of these instructions follows the data element numbers on the forth.) 490.54a MONITORING OF THE UNDER DISPENSER CONTAINMENT- Indicate the method used for UDC monitoring. 49454b. SPECIFY -11799 "Other" is checked, describe other 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 ofthe manufacturer of 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. 490.56. MODEL k - Enter 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 manufacturer ofthe sensor(s). 490-58. MODEL N(S) - Enter the model norther of the sections) installed. Ifadditional space is needed, use Section X. 49459. DETECTION OF A LEAK INTO THE UDC TRIGGERS AUDIBLE AND VISUAL ALARMS. Indicate Yes or No 490-60. UDC LEAK ALARM TRIGGERS PUMP SHUTDOWN- Indicate Yes or No 490-61. FAILURE/DISCONNECTTON OF UDC MONITORING SYSTEM TRIGGERS AUTOMATIC PUMP SHUTDOWN- Indicate Yes or No 49062. UDC MONITORING STOPS THE FLOW OF PRODUCT AT THE DISPENSER - Indicate Yes or No. 49063. UDC CONSTRUCTION - Indicate ifthe conetructim ofthe UDC is single -walled, or double -walled. 49064a DOUBLE -WALLED INTERSTITIAL SPACE MONITORING - Indicate what is used m monitor the interstitial space. 490-64b. LEAK WITHIN THE SECONDARY CONTAIMENT OF UDC TRIGGERS AUDIBLE AND VISUAL ALARMS - Indicate Yes or No 490-65. VII -I ELD TESTING -Check 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 Regdrements (i.e., UST has any single-wall component and is located within 1,000 feet of a public drinking water well). 49066. TESTING OF SECONDARY CONTAINMENT COMPONENTS EVERY 36 MONTHS - Check the box ifyou have secondary containment that requires testing. 49067. SPILL BUCKET TESTING - Check the box ifyou have spill buckets. 490 -68a -h. VIII 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 no, REFERENCE DOCUMENTS MAINTAINED AT FACILITY - Check the appropriate boxes to describe reference documents maintained at the facility. Note that the than two items on the list mum be kept in the facility. 490.69b. MONITORING PLAN: Indicate that this plan is kept as a reference document. 490-69c. OPERATING MANUALS FOR ELECTRONIC EQUIPMENT: Indicate that this plan is kept as a reference document. 490-W. CA UST REGULATIONS - Indicate that this is kept as a reference document. 490-69e. CA UST LAW - Irdicak that 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. 490.69g. 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. 4904%. SPECIFY-If-07='is checked, enter a brief description of the other documents) maintained at the facility. If additional space is cieded, see Section X. 49470. DESIGNATED OPERATOR TRAINING - Check this box to verify that this statement is the. 490.71. COMMENTS/ADDITIONAL INFORMATION- Make additional continents or you may attach and identify the number of additional pages of intervention to describe any additional UST system monitoring -related information (e.g, additional information required by you local agency) Attach any monitoring logs that you will be using for the monitoring ofyou tank system. 49472. NAME - Enter the name of the person who routinely conducts the monitoring and equipment maintenance under this plan. 49473. TITLE - Enter the title of the person. 49474. NAME- Enter the name of the second person if applicable, who routinely conducts the monitoring and equipment maintenance under this plan. 49475. TITLE - Enter the tide 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 signattae 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 49477. DATE - Enter the date the plan was signed. 49478. APPLICANT NAME - Print or type the name of the person signing the plan 49479. APPLICANT TITLE - Enter the title of Ne person signing the plan UPCF UST -D (12/2007) 414