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(Agency Use Oak) This pI as been mviewLd and. proved [I Approved Willi Conditions0 Disapproved Local Agency Signature: te: ........... ('.:omments or Special Con Dai to - ----------- .......... UPCF1 UST Monitoring Pfail - Page 2 Instructions Complete it 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 ol'changes in the information it contains. Please note that your local agency may require YOU 10 obtain approval lifia to installing or modifying monitoring equipment. (Note: Numbering ortlicse instructions follows the data element numbers on the form.) 490-54a. MONITORING OFTIIH UNDER DISPENSER CONTAINMENT. Indicate the method used lot UDC monitoring. 490-54b_spiciFy..irq9,,otb&*is checked,describe oilier method used. IrVI-1-1.VI-1-2 or VI-I-3 or VI-1-99 is checked.complete 490-55 to 490-64b. 490-55. IIANI.41.N4ANI1I'Ac*ruit1.,iz -Hiller lite name of tile mmullacturer of the inonitoringsymcin control panel(console). if tem is no control panel(e.g..only an electrical relay WX is installed)leave this space blank. 490-56. MODEL linter the model number fix lhemonitoring system control panel(console).Ifthere isnocontrol pa nd(e.g..only an elceirical relay box is installed)lcilve this space blank. 490-57. LEAK SENSOR MANUFACTURI:It_Enter the name of tile manufacturer Oftlic sensor(s). 490-58. MODEL AS)--Enter lite model nurnbcr or lite scuson(s)installed.Ifaddilionalspice is scaled,use Scoitill X. 490-59. Durcrloisl OF A LEAK INTO TUIE UDC TRIGGERS AUDIBLE AND VISUAL ALARMS. Indicate Yes or No. 490-00, UIX LEAK ALARM,riumimis PUMP SI IUTDOWN--Indicate Yes or No. 490-61. FA fLUR IUDISCONNECTION OF UDC MONITORING SYSTEM'l-RI00E RS AUTOM A*ric pu mi,S I I uTDOWN indicate Yes or No, 490102, VDC MONITORING STOPS T1113.FLOW oi,,PRODUCT'tA:i"rill-.DiSlIFNSI"-R-IndicaleYes orNo. 490-63. UIX CONSTRUCTION-indicate if the construction of the UDC is singIc-walled,or dolubic-walled. 490-(Aa. DOUBLE-WALLED INTU.RSTITIAL SPACE.MONITORING-Indicate what is used to monitor the interstitial Spam 490-(Al).LEAK wrrilINTHE',SrCONDARY CONTAINMEN*r OF UDCTRIGGERS AUDIBLE AND VISUAL ALARMS-•lotlicate.Yes-or No. 490-65, VII-1 FILL)TESTING Check the box if you have been notified by the Stale Water Resources Control Board(SWR(M)that the UST(s)covered by this plan islare sub�jccl(4)finhanced Leak Detection Recluiminents(i.e.,US-I"husany single-will Component and is located within 1.000 lect of public drinking water well), 490-66. TESTING OF SECONDARY CON'rAINMl-N*I'COrvlPON[-.N,rs EVERY 36 MON rl ISCheck the box ifyou havescoondary containnicitt Ural requires testing, 490-67. SPILL BUCKE r'rl:S'TING ..Check the box ifyou havc spill buckas. 490-68. Vill RECORDKf-.fTJNG..Indicate+Oiich monitoring and cquiprilcm maintenance recor(kare maimainud ror this facility. 490.69a. IXTRAINING STATI-I'MENT Check ibobox to verify that the slatemcni is true. mcm-m-Mrs MAI NTAINI.-J)A'I'FACILITY Check the appropriate boxes 14)describe retercmedocoments maintained at the facility. Note that the first two irons on the list must be kept at the racility. 490.60b.MONITORING PLAN:Indicate that this plait is kept nsa reference document. 490-(v9c.OPERATING MANUALS,FOR EQUIPMENT-Indicate thal this plan is kept as a reference docullicill. 490-69d.CA UST REGULATIONS--Indicate that this is kept a%;i relerentee document. 490-09e.CA USTLAW--Indicate that this is;kept as relerence document. 490-(+9f. STATE WATER RESOURCES CONTROL BOARD(SWRCH)PUBLICATION - "I IANDBOOK FOR'TANK OWNERS-MANUAL AND s*rA,rFS*rICAL INVENTORY RE-,C.ONCI LIATION":lodicitle that this,is kepi as wrorctice document. 490-69�g.SWRCI)PUBLICATION:"UNDERSTANDING AUTOMAncTANK GAUGING syS,r(..my,:Indicate that this is kept ax a rellemnee documcm. 490-69h.OTIIKIt...indicate that other reference docummils are kept. 490-09i. SPECIFY. If`C)'d'I IGR"is chcrkal+entC1'a brlCFdCSCriptiQn nC[hC Utter lhetllneni(%)nNtimaise<t:a tic facility.tl'adtfilionai space is ihCl'da1,5CC SSM 11<N1 X. 490-70. DFISI GNATED Oil ERATOR T 11 A I NING Check this box to verify that this statement is Iruc. 490-71. INFORMATION- Make additional comments or you may allavit and iticillify the number ofadditional pages of information to descril)c any additional UST systenh monitoring-related information additional information m-clitimd by your kwal agoicy). Attach any monitorini g log.-,that you will be using(or the monitoring ofyour tank system 490-72. NAME Enter lite name of the person who routinely coliducls the mortiloringand utuipuicni nrainicnaneu under this plait. 490-73. TITLE Enter the(iticofilic person. .190-74. NAM!-. Enter the mune or tile sceond pers-ou.ifappl icabic.who routinely conducts lite itagiii toringand LX11lipluclit maintenance tindul this plan. 490-75, TITLE E'Jitcr the title orlbesecond person. OWNI:Iti011i.:IZA'FORSI(iN'A'rURI: The hack ownerupperator,facility o%i-iicr!opeiiii(ir.or:iii;iiiihoriv.ctI sign in to sinus provided. This signature certifies that the signet believes that all infornialionsubmitiLd is ime.accuritic.and complete.and ilia[the liaining program specified in Section IX has ..........bxm imp1cmenl,;d....... ....... ......................... 490-70. RITRESHN HN(; CliLvk the appropriate box it) indicate whether lite signer i, the t.I.S1, owncr,opermor, the jj.5'r facimy tmm000perator. or am nuillorin-d reprC."clitadw ot,file owner. 490-77. DATE linter the date the plan w;+s signetf. 490-78. APPLICANTNAMI.: Iltint or type[lie manic of the person signing the plait. 490-79. APPLICANTITFIX •linterthe title ofthe per-mitsignim,the plait. uptCF us-r-i)(1212007)-414 www.iini(loc.i.org