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(Agency Use On/y) This plan has been reviewed and: [R/Approved 0 Approved With Conditions ❑Disapproved
<br /> Local Agency Signature: Date:
<br /> Comments at Special Conditions,
<br /> UPCF UST Monitoring Plan — Page 2 Instructions
<br /> Complctc a scparale UST Monitoring Plan for cacti UST monitoring system at the facility. This lbrm must be submitted with your initial UST
<br /> Operating Permit Application and within 30 days of changes,in the information it contains. Please note that your local agency may require you to
<br /> obtain approval REiff to installing or modifying monitoring equipment. (Note; Numbering of these instruction-,follows the data element numbers on
<br /> the lbrim.)
<br /> 490.54a. MONITORING 0F11iii IJNDKR DISPUNSUR CONTAINMLN'l'-Indicate the method used for EJUC mortit"ring.
<br /> 490-54b. SPECIFY-lj'99"Othurlis checked,describe other method used.
<br /> [fV)-)-I,vl-1-2c%rV[-1-3orV[-1-99ischce,ked,L-*Fmplc4c490-55to490-64b.
<br /> 490-55. PANNI.MANUFACTURER Enter the name of List rianul'acturur of The monitoring qysieni control panel(console). If there is no control panel(e.g.,only an electrical
<br /> relay box is installed)leave This spice blank.
<br /> 490-56. MODEL 0-Enter the model number lot-file monitoring system control panel(consolc) if there is no control Panel(e.g.,only all declsim-il relay box is installed)leave
<br /> this space blank.
<br /> 490-57. 1.12.AKSr,.NSORMANk)IrA(.['URr-.R Enter the name ofiltemanufacturer of ftsensor(r.).
<br /> 490-58. MOMI-sV(S) Enter the model number of theNersmir(%)installed.If additional space is rKaJua,use Section X.
<br /> 490-59. DETECIV.)N 01;A LEAK INTO TI It-'I JD('TRKR3 ERS A UDIBI.r.AND VISUAL ALARMS. Indicate Yes orNo.
<br /> 490-60•;0. UDC LEAK ALARM TRI(j(3ERS PUMP SHUTDOWN Indicate Yes of Nu.
<br /> 490-iii, FAILURE/DISCON NUC11ON OF UDC MONITOR I NXI i S YSTEM'I`R I(iQ F.R';AUTOMATIC PUMP SI I U,I,DOWN-Indicate Yes or No,
<br /> 490.62, UDC M0NI1`ORIN0,STOPS 11115 i'LOW or PRODUCT A7"rHE DISm;NSUR-Indicate Yes or No.
<br /> 490-63 UDC CONSTRUCTION Indit.-tic if the construction of the 1JDC is sini:le-walled,or dnljhlcs%vPl led.
<br /> 490-640, DOUBLE-WALLL-'DINI'r..RSTITIAI,SIIACL-MONITORING Indicate what is used to monitor the interstitial space.
<br /> 490-64b. LEAK WITHIN THF,. CONTAINMENT OP U1X'TRI0Gh'I(S AUDIBLE,AND VISUAL ALARMS-Indicatc Yes or No
<br /> 490-65, VII-I ELD I'LSI I NO-Check The Wx il'you have been notified by the Stsue Waite Resources Control Board(SWKCIS)that the UI.JiT(S)covered by this plan is/are
<br /> subject to Enhanced Leak Detection Requirements(i.e.,UST has any single-well component and is located within 1,000 fcc(of a public drinking water well).
<br /> 490-tiff. OF SECONDARY C0NTAfNMl;,N I COMPONENTS EVERY 36 MONTHS Chuck the,box it-you have secondary containment That rittlivirus lusting
<br /> 490-67. SPILL BUCKET TESTING Check the het;iryntj 1144Ve Spill buckets.
<br /> 490-611. Vill RECORDKELPtNO-Indicate which monitoring and equipment maintenance recurt1sare maintained for this facility.
<br /> 490-69a. IXTRAINING STATFMLN'r Chuck the box to verily that the statement ix True.
<br /> R121FLk1iNCIT rXXITIVIr-NMMAINTAINED AT FACILITY-(.,heck The approprinte boxes to describe reference dociinienis maintained at the theility. Note that the
<br /> first two items on the list must be kept 41 Ilse facility.
<br /> 490 69b.MONITORING PLAN Indicate that this plan is kept as a referunm document
<br /> 490-69c, (,101"FRATING MANUALS FOR ii,r,,cTRONJC UQUIPMVNT;Indicate that this plan is kept as a reference document.
<br /> 490-69d.(.A UST fZj;G1JLA*I'I0NS-Indicate(lint this is kept as a reference duciialuill.
<br /> 490-69e, CAUST LAW Indicate that this is kept as a reference document.
<br /> 490-69f. STATE WATER RESOURCES CoNmoi,BOARD(SWRCH)P1,1131,1CATION- "HANDBOOK FOR TANK OWNERS MANuAl,AND
<br /> STATISTICAL INVEN'roRY RPC(.'fN(:'ILIA'I ION":Indicate that chis is kept u%a r0brence document
<br /> 490-69g. SWR(7n PUBLICATION:"UNDERS I"ANDINO AUTOMATIC TANK GAUGING SYS'11-MS:Indicate that ihb,is kept ase reference document.
<br /> 4904;9h. OTHER Indicate that other reference documenisare kepi,
<br /> 490-69i. SPIJCIFY-If"071(FR"6 checked,enter a hTlet description of the olherdOCUllkent(s)maintained at the Ibcility.If additional space is needed,see Section X
<br /> 49(),70, DESIGNATED OPERATOR TRAINING Check this box to verify that this statement is true.
<br /> 490,71. COMMENTS/AC OITIONAL INFORMATION Make additional cunurivills or you may attach and identify the aunilier of additional pages orinibmiation to describe
<br /> any additional tAT system monitoring-related information(e.g.,additional information required by your local agency). Attach any monitoring logs flu"you will be
<br /> using for the monilofipj;oryour tank system
<br /> 490-72. NAME-linler the name of1he person who routinely CundlICEs;the monitoring and equipment maintenumu under chis:plan,
<br /> 490-73. 1111.11-Filter the title of the person.
<br /> 490-74. NAME' Enter the name of the second person.if applicable,who routinely conducts the moniwrinj!,and equipment maintenance under this plan.
<br /> 490-75. Tj,ri.13,-Enter the title of the second person.
<br /> OWNER/OPERATOR SIONATT)RR The Tank owngriOpffat0r,facility owner/operator,of all sluthoeivwd representative ofthe owner shall sign in the space luovided.
<br /> ThiAl6gimton:curlifivS that the signer believes that all information sutnninqj is true,accurate,and complete,and that the tiraininy prugram Specified in Section IX has
<br /> been implemented.
<br /> 490-76. Rr,,MFSFN'I'ING Check the approllilialt: box its indicate whether the signer is die UST owner/operator, the UST facility ownerloperstor, oc an authorivin)
<br /> rcpfescrill'ttive Of the owner
<br /> 490-77. DATL Enter iltedate the plan waNsiUnod,
<br /> 490-78. APPLICA 9rNAM U-Print or type the name or the person signing the plan.
<br /> 490-79. APPLICANT I-ITIA Rnler the title of the person signing,tliv plan.
<br /> IJP(.'F I IST-D(12/24107)-4/4 www.unidosts.org
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