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(Agency Use Only) This plan has been reviewed and: !� roved ❑Approved With Conditions ❑Disapproved Local Agency Signature:_,--7-0'.A /' : -'- Dale: Comments or Special Conditions: U - UPCF 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 vdthtn 30 days of changes in the information it contains. Plesse note that you local agency may require you to obtain approval prior to installing or modifying monitoring equipment (Note: Numbering of these inslractions follows the data element numbers on the form.) 490-54a.MONITORING OF THE UNDER DISPENSER CONTAINMENT-Indicate the methal used for UDC monitoring. 490-54b.SPECIFY-IF99"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 490-646. 490.55. PANEL MANUFACTURER-Enter the name of the manufacturer of the monitoring system comm!panel(console). If there is no control panel(e.g.,only an electrical relay box is installed)leave this apace blank. 490-56. MODEL#-Enter the model number for the monitoring system control panel(console).If them is no control panel(e.g.,only an electrical relay box is imtalled)leave this space bladL 490-57. LEAK SENSOR MANUFACTURER-Enter the name of the manufacturer of the senam(s). 490-58. MODEL#(S)-Enter the model number of the seasor(s)installed.If additional apace is needed,use Section X 490.59. DETECTION OF A LEAK INTO THE UDC TRIGGERS AUDIBLE AND VISUAL ALARMS. Indicate Yee or No. 490-60. UDC LEAK ALARM TRIGGERS PUMP SHUTDOWN-Indicate Yes or No. 490-61. FAU-URFJDISCONN13CTION OF UDC MONITORING SYSTEM TRIGGERS AUTOMATIC PUMP SHUTDOWN-Indicate Yes or No. 49MI UDC MONTTORING STOPS THE FLOW OF PRODUCT AT THE DISPENSER-Indicate Yes or No. 490-63. UDC CONSTRUCTION-indicate if the construction of the UDC is singlo-walled,or doublewallod. 490-64a,DOUBLE-WALLED INTERSTITIAL.SPACE MONITORING-Indicate what is used to monitor the interstitial space. 490-64b.LEAK W('TIIN'rM SECONDARY CONTAINMENT OF UDC TRIGGERS AUDIBLE AND VISUAL ALARMS-Indicate Yes or No. 490-65. VH-1 ELD TESTING-Check the box if you bane been notified by the State Water Resources Control Bard(SWRCB)that the UST(s)covered by this plan is/am subject to Enhanced Leak Detection Requirements(i.e.,UST has any singlo-wall component and is located within 1,000 feet of a public drinking water well). 490-66. TESTING OF SECONDARY CONTAINMENT COMPONENTS EVERY 36 MONTHS-Check the box if yen have secondary containment that requires testing. 490-67. SPILL BUCKET TESTING-Check the box if YOU have spill buckets. 490.68. VII RECORDKEEPING-Indicate which monitoring and equipment maintenance meads are maintained for this facility. 490-69a. IX TRAINING STATEMENT-Check the box to verify that the statement fa true. REFERENCE DOCUMENTS MAINTAINED AT FACILITY-Check the appropriate boxes m describe ref ce documents maintained at the facility. Note that the first two items on the lint must be kept at the facitty. 490-696.MONITORING PLAN:Indicate that thio plan fa kept as a reference document- 490-69C. ocument490.690. OPERATING MANUALS FOR ELECTRONIC EQUIPMENT:indicate that this put is kept as a tefemuce document. 490.694 CA UST REGULATIONS-Indicate that this is kept as a reference documrnt 490-69e. CA UST LAW-bdicate that this is kept as a reference document 490-69f. STATE WATER RESOURCES CONTROL BOARD(SWRCB)PUBLICATION--HANDBOOK FOR TANK OWNERS-MANUAL AND STATISTICAL INVENTORY RECONCILIATION":Lmlicate that this is kept as a reference document 490-69g.S WRCB PUBLICATION:"UNDERSTANDING AUTOMATIC TANK GAUGING SYSTEMS":Indicate that this is kept as a reference document. 490-69b. OTHER-Indicate that other reticence documents am kept 490-69i. SPECIFY-If"OTHER"is checked,enter a brief description of the other documenl(s)maintained at the facility.Ifadditional space is needed,see Section X 490-70. DESIGNATED OPERATOR TRAINING-Chock this box to verify that this statement u true. 490-71. COMMENTS/ADDITIONAL INFORMATION-Make additional comments or you may attach and identify the number of additional pages of information to describe any additional UST system rmnitoring-mined information(e.g.,additional information roTired by your local agency). Attach any mordtering logs that you will b- using fm the monitoring of your tank system 490-72. NAME-Enter the name of the person who routinely condacts the monitoring and equipment maintenance under this plan. 490-73. TITLE-Enter the tide of the person. 490-74. NAME-Enter the name of the second person,if applicable,who routinely conducts the monitoring and equipment maintenance under this plan 490-75. TITLE-Enter 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 hue,accumlF 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. 49047. DATE-Eater the dam the plan was signed. 490-78. APPLICANT NAME-Print or type the came of the person signing the plan. 490-79. APPLICANT TITTLE-Enter the title of the person signing the plan. UPCF UST-D(12!2007)-4/4 wxw.unidocs.ore