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This�t has '+ Am 47hte Cot .s Caenmeats at h C � ;X � � t UST Monitoring P1 —Page Z 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 within 30 days of changes in the information it contains. Please note that your local agency may require you to obtain approval to installing or modifying monitoring equipment. (Note: Numbering of these instructions follows the data element numbers on the form.) 490-54a.MONITORING OF THE UNDER DISPENSER CONTAINMENT Indicate the method used for UDC monitoring. 490-54b.SPBCIFY-If 99-Other"is checked,describe oUra method used. "-I VI-1-2 or VI-I-3 or VI-1-99 is checked,complete 490-55 to 490-64h. 490.55. PANEL MANUFACTURER-Enter the new of the manuflicturar of the monitering system control pand(console). If there is no control panel(e•g,only an electrical relay boot is" the this space blank. 490-56. MODEL#- Enter the model number for the monitoring system control panel(console).If there is no control pand(e g.,only an electrical relay box is installed)leave this space blank. 490-57. LEAK SENSOR MANUFACTURER-Enter the nome ofthe manufacturer oftha s). 490-58. MODEL#(S)•Enter the model number of the sonsor(s)installed.If is nood4 use X. 490-59. DETECTION OF A LEAK INTO THE UDC TRIGGERS AUDIBLE AND VISUAL ALARMS. Indicate Yes or No 490.60. UDC LEAK ALARM TRIGGERS PUMP SHUTDOWN Indicate Yes or No 490.61. FAILUREMISCONNECTION OF UDC MONITORING SYSTEM TRIGGERS AUTOMATIC PUMP SHUTDOWN Indicate Yes or No 490-62. UDC MONITORING STOPS THE FLOW OF PRODUCT AT THE DISPENSER Indicate Yea or No. 490-63. UDC CONSTRUCTION Indicare ifthe construction of the UDC is single-walled,or double-walled. 490-64a.DOUBLE WALLED INTERSTITIAL SPACE MONITORING-Indicate what a used to monitor the interstitial space 490-64b.LEAK WITHIN THE SECONDARY CONTAIMENT OF UDC TRIGGERS AUDIBLE AND VISUAL ALARMS Indicate Yes orNo 490.65. VII-I ELD TESTING Check die box if you have been notified by the State Water Resources Control Board(SWRCB)that the UST(s)covered by this plan is/are subject to Enhanced Leak Detection Requirements(i.e.,UST has any a and a located within 1,000 feet of a public well). 490-66. TESTING OF SECONDARY CONTAINMENT COMPONENTS EVERY 36 the box ifyou have secondary containment 440.67. SPELL BUCKET TESTING Chock the boc if you have spill buckets. 490-68".VIII RECORDKEEPINO 4ndicate which monrtonag and equipment moratorium records are maintained for this facility. 4 IX TRAINING STATEMENT Check the bot to verify that the statement is tr►e. REFERENCE DOCUMENTS MAINTAINED AT FACILITY-Check the appropriate boxes 4a describe reference documents maintained at the facility. Nord that die first two item on the list must be kept at the flicility 490.69b. MONITORING PLAN:Indicate that this plan is kept as a refervitoo documett 490-ft OPERATING MANUALS FOR ELECTRONIC EQUIPMENT this plan is kept as a reference document. 4 CA UST REGULATIONS Indicate that this is kept as a reftence document 490-69e. CA UST LAW Indite that this is kept as a reference document 4 STATE WATER RESOURCES CONTROL BOARD(SWRCB)PUBLICATION- -HANDBOOK FOR TANK OWNERS•MANUAL AND STATISTICAL INVENTORY RECONCILIATION Indicate that this is kepit as a rderence document, 490.698.SWRCB PUBLICATION:"UNDERSTANDING AUTOMATIC TANK GAUGING SYSTEMS"'Indicate tat this is kept as a refavoce document 4 Indicate that other reference documents we kept I 440-69h. S -If -is chocked.anter a briefdesoription of the other dace s)mandamed at to facility If additional space is nec&4 we Section X 490-70. DESIGNATED OPERATOR TRAINING Check this box to verify that this statement is tete. 490-71. CO ADDITIONAL INFORMATION-Make additional comments or you may aftach and identify the number ofadditional pages of"information to describe any additional UST*went m (a g..additional information required by your local ) AUwh any monitann loga did you will be using for the Monitoring of your tank system. 490-72. NAME-Enter the ranee of the person who routinely conducts the monitoring and equipment maintenance under this plan. 490.73. TITLE Enter the title of the 490-74.N -Enter the name of the second parson,if applicable,who routinely cooducts the monitoring and equipment reaftranance under this plan. 490-75. the title of the second person. OWNER/OPERATOR SIGNATURE-The tank owner/operator,facility owner/operaw,or an authorized representative of the owner shall sign in the space This signature certifies that the signer believes that all information submitted is true,accurate,and compleb,and that the training piciparn specified in Section IX has been implemented. � 490-76 REPRESENTING-Check the appropriate box to indicate whether the signer is the UST ownisd ,*a UST hicility ownedoperatw,or an authorized representative of to owner 490-77. DATE-Enter the tato the plan was signed. 490-78. APPLICANT NAME-Print or"a the nome ofte person signing die plan. 490-79 APPLICANT TITLE-Enter the tits of the person signing the plan. UPCF UST-D(I 4/4