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UST Monitoring Plan - Page I Instructions
<br />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
<br />Application and within 30 days of changer in the information it contains. Please note that your local agency may require you to obtain approval prior to installing or
<br />modifying monitoring equipment. (Note: Numbering of these instructions follows the data element numbers on the form)
<br />490-1. TYPE OF ACTION - Check the appirpriste box to indicate why this plan is being submitted.
<br />490.2. PLAN TYPE - Check the appropriate box to indicate whether this plan covers all, or merely some, ofthe USTs in the facility. If the plan covers only some ofihe tanks,
<br />identify those tanks in the space provided [e.g., by using the Tank ID #(s) in item 432 ofthe UST Operating Permit Application - Tank Information Form(s)].
<br />1. FACILITY ID NUMBER - This space is for agency use only.
<br />3. BUSINESS NAME - Enter the complete Facility Name,
<br />103. BUSINESS SITE ADDRESS - Enter the street address where the facility is located, including building number, if applicable. Post office box numbers arae not acceptable
<br />This information must provide a means to locate the facility geographically.
<br />104. CITY - Enter the city or unincorporated area in which the facility is located.
<br />490.3a MONITORING EQUIPMENT IS SERVICED - Check the appropriate box to specify the frequency of monitoring equipment testing/certification,
<br />490.31, Specify Other frequency for monitoring equipment servicing.
<br />490.4 SITE PLAN - Indicate if a site plammap is submitted with this monitoring plan or if it was submitted previously and is current for the facility. Monitoring plans mug include
<br />a Site Plot Plan/Map showing the tank and piping layouts end the locations where monitoring is performed (i.e., location ofsemms, probes, line leak detecun, monitoring system
<br />conhol panel, dc.).
<br />490.5 IV- I CONTINUOUS ELECTRONIC MONITORING -Indicate if this monitoring method is being used to monitor the tanks.
<br />490.6 SECONDARY CONTAINMENT- If IV -I is checked, check the appropriate box to describe the environment inside the tank secondary, containment.
<br />490.7 PANEL MANUFACTURER --If IV -1 is chocked, enter the orae of the manufacturer ofthe monitoring system control panel (console).
<br />490-8 MODEL # - ITIV-1 is checked, enter the model number for the monitoring system control panel.
<br />490-9 LEAK SENSOR MANUFACTURER - If IV -1 is checked, enter the name ofthe manufacturer of the sensor(s). If additional space is needed, use Section X.
<br />49610 MODEL #(S) -- If IV -I is clucked, color the model number for each type of sensor installed. If additional space is needed, use Section X.
<br />49611 IV -2 AUTOMATIC TANK GAUGING -Indicate iftlds method is used for monitoring the UST's.
<br />49412 PANEL MANUFACTURER- If IV -2 is checked, enter the more, ofthe manufacturer ofthe monitoring system control panel (console).
<br />49613 MODEL # - ITIV-2 is checked, color the model number for the monitoring system control panel.
<br />49614 IN -TANK PROBE MANUFACTURER - If IV -2 is checked, enter the name of the manufacturer of the probe(s).
<br />49615 MODEL #(S)- If IV -2 is checked, enter the model number for each type of in -tank probe installed. If additional space is needed, use Section X.
<br />49616. LEAK TEST FREQUENCY - If IV -2 is checked, check the appropriate box to describe the in -tank leak test frequency.
<br />49617. SPECIFY- If 490-16e is checked, color the frequency of programmed leak tests.
<br />49618. PROGRAMMED TESTS - ICIV-2 is checked, check the appropriate box to describe the tests programmed into the ATG system
<br />49619. SPECIFY- If 49618c is checked, enter the frequency ofin-tank leak testing.
<br />49620. IV -3 INVENTORY RECONCILIATION - Check the box if statistical inventory reconciliation is performed.
<br />49621. IV -4 WEEKLY MANUAL TANK GAUGING. Indicate ifthis method is used to monitor the tanks.
<br />490-22. TESTING PERIOD- IfI 4 is checked, check the appropriate box to describe the MTG testing period.
<br />49623. IV -5 TANK INTEGRITY TESTING: Indicate if this method is used to monitor the tanks.
<br />490-24. TEST FREQUENCY - If IV -5 is checked, check the appropriate box to describe the frequency of tank integrity testing.
<br />49625.OTHER: If 490-24c is checked, specify other test frequency.
<br />49626. IV -99 OTHER Indicate ifmonitoring of the tanks occurs that is not indicated in any other category.
<br />49627. If IV -99 is checked, enter a brief description of the other tank monitoring method(s) used (e.g., vedose zoo monitoring per 23 CCR §2647, groudweter monitoring per
<br />23CCR §2648). Include the monitoring frequency (e.g., Continuous, Weekly). Ifadditional space is needed, use Section X.
<br />490-28. V-1 CONTINUOUS MONITORING OF PIPE/PIPING SUMP(S) AND OTHER SECONDARY CONTAINMENT WITH AUDIB LE AND VISUAL ALARMS:
<br />Indicate ifthis is the monitoring method used for the piping.
<br />49629. SECONDARY CONTAINMENT: If V -I is checked, Check the appropriate box to describe the environment inside piping secondary containment.
<br />490-30. PANEL MANUFACTURER - If V-1 is checked, emer the time ofthe manufacturer ofthe monitoring system control panel (console).
<br />49631. MODEL # - If V-1 is checked, color the model number for the monitoring system control panel.
<br />49632. LEAK SENSOR MANUFACTURER- If V-1 is checked, enter the name ofthe manufacturer ofthe senson(s).
<br />49633. MODEL #(S)- If V-1 is checked, enter the model number for each type ofsensor installed. b additional space is needed, use Section X.
<br />49634. PIPING LEAK ALARM TRIGGERS AUTOMATIC PUMP SHUTDOWN - If V-1 is checked. check Yes or No.
<br />49635. FAILURE/DISCONNECTION OF THE MONITORING SYSTEM TRIGGERS AUTOMATIC PUMP SHUTDOWN- If V-1 is checked, clack Yes or No.
<br />49636. V-2 PIPE MECHANICAL LINE LEAK DETECTORS PERFORM 3 GPH LEAK TESTS: Indicate ifthis monitoring method is used to monitor the pipelines.
<br />49637. MLLD MANUFACTURER(S) - If V-2 is checked, enter the camels) ofthe manufactura(s) ofthe mechanical line leak detector(s). If additional space is needed, use
<br />Sectio X
<br />49638. MODEL #(s) - If V-2 is checked. Enter the model number for each type of mechanical line leak detector installed. If additional space is needed, use Section X.
<br />490-39. V-3 PIPE ELECTRONIC LINE LEAK DETECTORS: Indicate ifthis monitoring method is used to monitor the pipelines.
<br />490.40. ELLD MANUFACTURER- If V-3 is checked, Enter the name of the menufacturcr of the electronic line leak derectri
<br />490-41. MODEL #(S)t- If V-3 is checked, oder the model number for each type of electronic line leak detector installed. If additional space is needed, use Section X.
<br />49442. PROGRAMMED LINE INTEGRITY TESTS -IfV-3 is checked, check the appropriate box to describe the type oftests programmed into the monitoring system.
<br />49643. ELLD DETECTION OF A PIPING LEAK ALARM TRIGGERS PUMP SHUTDOWN - If V-1 is checked, cheek Yes or No.
<br />49644. ELLD DETECTION OF A PIPING LEAK FAILURE/DISCONNECTION TRIGGERS PUMP SHUTDOWN. - If V -i is checked, check Yes or No.
<br />490-45. V4 P@E INTEGRITY TESTING - Indicate ifthis monitoring method is used in monitor the pipelines.
<br />49046. TEST FREQUENCY - If V4 is checked, check the appropriate box to describe the frequency of pipe integrity testing.
<br />490-47. SPECIFY -11490.4699 is checked, enter the frequency ofpipe integrity testing.
<br />49048. V-5 VISUAL PIPE MONITORING - Indicate ifthis monitoring method is used to monitor the pipelines.
<br />490-49. ITV -5 is clocked, check the appropriate box to describe the frequency of visual monitoring.
<br />490-50. SUCTION PIPING MEETS EXEMPTION CRITERIA - Indicate ifthis monitoring method is used to monitor the pipelines.
<br />49651. NO REGULATED PIPING PER HEALTH AND SAFETY CODE, DIVISION 20, CHAPTER 6.7 IS CONNECTED TO THE TANK SYSTEM - Check this box if no
<br />piping in the tank system is regulated under the UST law, or there is no piping.
<br />490-52. V-99 OTHER - Indicate if another method is used for pipeline monitoring
<br />49653. SPECIFY- Enter a brief description ofthe other line monitoring method(s) used. Ifadditional space is needed see Section X. Be sure to clearly describe
<br />monitoring melhod(s) and frequency.
<br />This monitoring plan must include a Site Plan showing the general tank and piping layouts and the locations where monitoring is performed (tee., location of each sensor, line leak
<br />detector, monitoring system control panel, de.). If you already have a diagram (eg., current UST Monitoring Site Plan from a Monitoring System Certification form, Hazardous
<br />Marrieds Business Plan map, etc.) that shows all required information include it with this plan.
<br />UFCF UST -D (12/2007) 2/4
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