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rA roved ❑Approved With Condition. Utssppntved (Agehc7'(Ise 0af)) This plan has been ret,iewed and r 1 PPS'^r Local Agency Signature. Date: "/ Comments or Special Conditions UPCF UST Monitoring Plan — Page 2 instructions at the facility. This form must be submitted with Your initial UST Complete a separate UST Monitoring Pian for each UST monitoring system that Your local agency may require Y operating Permit App ui ment. (Note: Numbering of these instructions follows the data element numbers on Application and within 30 days of changes in the information it contains. Please note obtain approval prior to installing or modifying monitoring equipment- the q P the form.) 490-54a. MONITORING OF THE UNDER DISPENSER CONTAINMENT Indicate the method used for UDC'monitoring. 490 54b. SPECIFY-If 99"Ca[�er-'is checked,describe other method used. l(e,g.,only an electrical yl_1__or VI-]-3 or VI-1-99 is checked.complete 490-55 to 490-64b. If V1-1-1• system control panel(console). If there is no cpnno Parra MANUFACTURER-Enter the name of the manufacturer of the monitoring only an electrical relay box is installed)leave 490 55. PANEL MANUF leave this blank le If there is no control panel(e g.• relay box is installed)ka �e {(Console). 490-56. MODEL.#-lir the model number for the monitoring system control P� this space blank. of the manufacturer of the sensor(s). 490 57 LEAK SENSOR MANUFACTURER-Enter the name is needed,use Section X 490-58. MODEL NS -Enter the model number of the sensors)installed.If additional space TRIGGERS AUDIBLE AND VISUAL ALARMS Indicate Yes or No 490-59 DETECTION OF A LEAK INTO THE UDCSHUTDOWN_Indicate Yes or No vrN_Indicate Yes or No. 490-60 UDC LEAK ALARM TRIGGERSERS AUTOMATIC PUMP SHUTDOWN 490-61 FAILURE/DISCONNECRON OF UDC MONITORING SYSTEM TRIGGERS -indicate Yes or No. 490-62. UDC MONITORING STOPS THE FLOW OF PRODUCT AT THE e-walled,or double-walled. 490-63 UDC CONSTRUCTION-Indicate if the conmuction of the UDC is single-walled. w monitor the interstitial space SPACE OF UDC TRIGGERS AUDIBLE AND VISUAL ALARMS-Indicate Yes or ST b this Plan is are 490-64a. DOUBLE-WALLED INTERSTITIALONTAIMNMEN[ F U -Indicate what is SWRCB)fat the UST(s)covered 5' 490 64b. LEAK WITHIN THE SECCI the State Water Resources Control Board Requirements(i.e.,UST has any single-wall comPonent and is located within l.�few of a public drinking water well). 490-65 LEA WIELD TESTING-Check the box if you have been notified by �containment that requires testing. subject to Enhanced Leak Detection Req COMPONENTS EVERY 36 MONTHS-Check the box if you have sato 490,b6. TESTING OF SECONDARY CONTAINMENT buckets. for this facility. 490.67 SPILL BUCKET TESTING-Check the box if you have spill maintenance records are maitttainod 490-68 VIII RECORDKEEPiNG-Indicate which monitoring and equipmentrite maintained at the facility Note that the 490-69a. IX TRAINING STATEMENT-Check the box AT FACILITY verify that e statement Check the appropriate boxes to describe reference docume REFERENCE DOCl1M1N1S MAINTAINED first two items on the list must be kept at the facility. 490-69b. MONITORING PLAN:Indicate that this pian is kept as a reference document this plan is kept as a rrfcrertct docurnent. FOR ELECTRONIC EQUIPMENT=[amu haten P 490-69a OPERATING MANUALSdocument. 490-69d. CA UST REGULATIONS-indicate that this is kept as a reference 490{9e. CA UST LAW-Indicate that this is kept as a reference document 490-69f. STATE WATER RESOURCES CONTROL BOARD indicateR�t)PUBLIC BL s keApt Lns a reference-HANDBOOK FOR TANK OWNERS-MANUAL ANent. STATISTICAL INVENTORY RECONCIL this is kept as a reference docum 490-699. SWRCB PUBLICATION:"UNDERSTANDING AUTOMATIC TANK GAUGING SYSTEMS":Indicate ism sae Section X. 490 69h.OTHER-indicate that other reference documents are kept of the other document(s)maintained at the facility.If additional space 490 69i, SPECIFY-if-OTI ER"is checked,enter a brief description that this statement is true. of information to describe TOR TRA[NLNG-Check this box to verify you may attach and identify the number of additional pages that you will be 490-70. DESIGNATED OPERA Attach any monitoring logs 490-71 COMffiW S/ADDITIONAL INFORMATION-Make additional Commenu or Y Y any additional UST system monttonng- related information(e-g-,additional information required by your local agency). using for the monitoring of your tank systemmonitoringiag and equipment maintenance under this plan. 490-72. NAME- Enter the name of the Person who routinely conducts the490-73. TITLE-Enter the title of the person. if applicable,who routinely conducts the monitoring and equipment maintenance under this plan 490-74. NAME-Enter the name of the second person apP in the space provided. 490 75 TITLE-Enter the tide of the second person of the owner shall sign The tank owner/operator,facility owner/operator,or an authorized represenlatrve ra amspecified in Section IX has OWNERIOPERATOR SIGNATURE- let and that the training p gT This signature certifies that the signer believes that all information submitted is true,accurate,and complete, been implemented. the UST facrTit}' owner/operator' or an Authorized490-76. REPRESENTING - Check the appropriate box to indicate whether the signer is the UST owner/operator, representative of the owner. 490-77. DATE-Eater the date the plan was signed. NAME-Print the name of 490-79 APPLICAN o TITLF-Enter the title of the personhsigninginthe plan the plan UPCF LIST-D(1212007)-414 ww'v.uaidocs.org