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AWL Formatted Table [211
<br /> n
<br /> !! ITO3
<br /> (Agency Use Ort/y) This plan has been reviewed and: Approved ❑Approved With Conditions ❑ Deleted:UDC MONRING
<br /> Disapproved r,r
<br /> Deleted:SPECIFY-If item 49
<br /> �e '!r ,• 4
<br /> Local Agency Signal=: /�ff�,At � f-79'✓+— Date: !d`( t,;3
<br /> �t r,,,
<br /> Deleted:LEAK MONITOR
<br /> ___11:&
<br /> Commits or Special Conditions: Deleted:MODEL#-If item 4 •• 6
<br /> Formatted
<br /> i!rlir
<br /> irr!n Deleted:LEAK SENSOR ••• 8
<br /> UPCF UST Monitoring Plan—Page 2 Instructions „;;; Deleted:MODEL#(s)-If it •••r91
<br /> ;
<br /> Complete a separate UST Monitoring Plan for each UST monitoring system at the facility. This form must be submitted with your initial UST ,;; '' r Formatted 10
<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 ,' r!;;; Deleted:WILL DETECTION 11
<br /> obtain approval prior to installing or modifying monitoring equipment (Note: Numbering of these instructions follows the data element numbers on r r
<br /> xp r D0leted:WILL UDC LEAK 12
<br /> the form. o
<br /> - - Formatted
<br /> 490-54a.MONITORING OF THE UNDER DISPENSER CONTAINMENT-Indicate the method used for UDC monitoring _
<br /> 490-54b.SPECIFY If 99"Other'.ischecked describeothermethodused,r _-_._ _____-_-- -",_ "."___"_".. _ _ ."__ __ _,_,_ "_"._. ___ _' en;;,'!r .• 14
<br /> Deleted•WILL
<br /> If VI-1-1 Vt_I-2 or VI-I_3 or V[_1=99 is-checked,C0 490-55 _64b, !'!;r;,
<br /> 11 490-55. PANEL MANUFACTURER-Enter name of the manufacturer of the monitors system controlpanel lconsole�f there is no control ane) e. y_--" '�+"rr n r Formatted ••• 15
<br /> p-__(g opt an electrical r.
<br /> relay box is installed_)leave thts space b1ank" Deleted:WILL UDC MONIT 16
<br /> 490-56. MODEL#-Enter the model number for the monitoring system control panel(consolej_If there is no control panel leg,only an elecmcal relay box is installed]leave !! ,r r, '•
<br /> this space blanks--_-_. _ _ _-..__ .."..-.-_ .. _._._ --_-_._. !„'; 17
<br /> De UDC CONSTRUCT
<br /> 490-57. LEAK SENSOR_MANUFACTURER-=Enter the name of themufactu -of the sen �'
<br /> - - -_ _- ---- - Formatted
<br /> 490-58. MODEL#(S)--Enter the model number of the sensorAsinstalled_If addmonal_space is needed use Section X. a;, ,a ... 18
<br /> 490-59. DETECTION OF A LEAK INTO THE UDC TRIGGERS AUDIBLE AND VISUAL ALARMS Indicate Yes or No Deleted:UDC INTERSTITIA 19
<br /> 490-60. UDC LEAK ALARM TRIGGERS PUMP SHUTDOWN-_Indicate Yes or Nom_ ___ �
<br /> 490-61. FAILUREMISCONNECTION OF UDC MONITORING SYSTEM TRIGGERS AUTOMATIC PUMP SHUTDOWN Indicate Yes or Nq.__ __ _ _ __ _r.,;,' Formatted Table ••. 20
<br /> 490-62. UDC MONITORING STOPS THE FLOW OF PRODUCT AT THE DISPENSER=_Indicate Yes or Noa___- �i, ----
<br /> -- -- - - -- -
<br /> 490-63. UDC CONSTRUCTION-Indicate if the construction of the UDC is single-walled or double walled Formatted
<br /> ____-_ ••• 21
<br /> 490-64a.DOUBLE-WALLED INTERSTITIAL SPACE MONITORING-Indicate what is used to monitor the interstitial soave. - Deleted:---.-----------__-_ leted:WILL DETECTION ... 22
<br /> ,190-64b.LEAK WITHIN THE SECONDARY CONTA IMENT OF UDC_TRIGGERSAUDII3LE AND --—_--—-S--Indicate Yes or Nom_ -- -_ Fu_,_�a�_�___- �
<br /> 490-65. VII4 ELD TESTING-Check the box if have been notified by the State Water Resources Control Board(SWRCB)that the UST(s)covered by this plan is/ Deleted:VII.PERIODIC SY •t [23]l
<br /> subject to Enhanced Leak Detection Rgguiremems(i.e.,UST has any single-wall component and is located within 1000 feet of a public drinking water well),.
<br /> ._.____"..".." Deleted:ELD TESTING-Ch
<br /> 490-66. TESTING OF SECONDARY CONTAINMENT COMPONENTS EV ERY 36 MONTHS"__Check the box if you have secondary containmentthat requires testings ... 24
<br /> ,190-67. SPILL BUCKET TESTING Check the box ifyou have spill buckets. <�. \
<br /> __ — _:. = z _ _______________________________ Formatted
<br /> ,490-68. VIII RECORDKEEPING=Indicate which momtoring and equipment mamtenance_records are maintained for this faailiryx_•• ... 25
<br /> 490-69a.IX TRAINING STATEMENT Check the box to verify that the statement is_true. a,\, Deleted:SECONDARY ••• 26
<br /> REFERENCE DOCUMENTS MAINTAINED AT FACILITY-Check the appmpriate_boxes to_describe reference documents maintained at the facility,_Note that the e,
<br /> --- - ---- - ------ - -
<br /> first two items on the list must be kept at the facility, ". .• 27
<br /> 490-69b.MONITORING PLAN_Indicate that this plan is kept as a reference document:
<br /> 490-69c,.OPERATING MANUALS FOR ELECTRONIC EQUIPMENT__Indicat that this is_kept as a reference document,__ _ __.
<br /> Deleted'SPILL BUCKET TE 28
<br /> 490=69d,CA UST REGULATIONS--Indicate that this is kept as a reference document. •` i fileted:VHid.RECORD KE 29
<br /> 490-69e,CA UST LAW-_Indicate that this is kept._as a reference document. <`,..`.a
<br /> 490 69E.STATE WATER RESOURCES CONTROL BOARD.(SWRCB)PUBLICATION:":'HANDBOOK FOR TANK OWNERS MANUAL AND .,,� " Deleted:MONITORING/MA ,•• 30
<br /> STATISTICAL INVENTORY RECONCILIATION], Indicate that this is kept as a reference document -.. _.-. _ _ - --_.®;\, i\ Deleted:IX.TRAINING 31
<br /> 490-69&SWRCB PUBLICATION UNDERSTANDING-AUTQMATICTANKGAUGINGSYSTEMS" di
<br /> :Incatetthtsas
<br /> _ha_tisk tareferenc_e__d_ocument_. "'
<br /> 490-69h,OTHER-Indicate that other reference documents are kept. Deleted:Check the box for it 32
<br /> 490-69i, SPECIFY,-If If"OTHER".is check_edbenter_a brief des-cripti-onof the other documentjs.P_maintained at the facility,[f additional space is needed see Section_X� _ ri
<br /> ,190-70. DESIGNATED OPERATOR TRAINING Check this box to veri that this statement is true ~1�`\�� FOrmatLBd ... 33
<br /> _.fY ..,,L-------------------------
<br /> identify h n f additional es of information to describe.
<br /> 490-71. COMMENTS/ADDITIONAL INFORMATION -Make additional comments or you may attach and t e umber o pag ,,i
<br /> Formatted f 341
<br /> any a_dditional_USI'system monitoring-related information_(e g-y additional_information_t'equired byyour Iocal_agencylAttach any monitoring logs_that-you ryill_be '," ••
<br /> a - --_using for the monuoring.ofypig tank systerry_--_ _--_ _ ---_- - _ _____ -- -- --- ---. _ _1, ;i�'
<br /> 490-72. NAME Enter the name of the person who routine) conducts the monitoring and ui ment maintenance under this Ian
<br /> .;
<br /> 35
<br /> 490-73. TITLE Enter the title oftheperson� _ _. _ _ _ `r Formatted
<br /> 36
<br /> 490-74. NAME Enter the name of the second gerson�jfapplicable,who routinely conducts the monrtonng_and a ujpment maintenance under thjs plan _ �l
<br /> ,190-75._TITLE Enter the title of the second o_erson 1 i ,�
<br /> Formatted
<br /> ... 37
<br /> OWNER/OPERATOR-SIGNATURE--The tank owner/operatorfacility owner/operato,-or_an authorized re�resentativ_e of the owner shalt sign in the Tace provided 4t)”'�1
<br /> -- ------ ---------- - tai ''.;,'., Formatted 38
<br /> This signature certifies that the signer believes that all information submitted is true accurate and complete and that the training program specified in Section IX has ,ye
<br /> been implemented. - -1'P �, F�fAlalCed ...(391
<br /> 490-76. RESENTING Check the_appropnate_box_to indicate whether the si er is_the_UST_owner/o_" the UST facility owner/o_ to moran_authorizeda
<br /> representative of the owners_._ _._-",-- __ _
<br /> ,f) ..r4011
<br /> 490-77. DATE Enter the date the plan was sign____ __. __ _.- ___ _ 'aJ 4
<br /> -- --- --- ------- , `` Deleted:SPECIFY---- -If item 4
<br /> 490-78. APPLICANT NAME=Print or type the name of the person signingtheplan�_ _ ... 41
<br /> - ---
<br /> 490-79. APPLICANT TITLE-Enter the ride of the g_ p -_" ___ _- _ _ _ ". _ "."._.. j FOrmatted Table
<br /> _ person stgnin the lap
<br /> - -N b,
<br /> 42
<br /> di t�nicr.�! Deleted:DESIGNATED UST •• 43
<br /> dryrtn�,p.r�i
<br /> di' •,tLP''1 Deleted:X.
<br /> 44
<br /> Formatted
<br /> Formatted q(r
<br /> Deleted:You may use this secF.,f4jj
<br /> :XI.PERSONNEL
<br /> Formatted --- 50
<br /> UPCF UST-D 121200 = /5 _ w_w__w.un ocs.o a"l Formattlad
<br /> F5111
<br /> dr;!°'` Deleted:NAME-Enter then 52
<br /> purr+;
<br /> Deleted:TITLE-Enter the tit rqAi
<br /> 54
<br /> vr.
<br /> I trua �
<br /> 'ttl" FormaEt'ad 57
<br /> P'"' FcOrmattad Table 58
<br /> FormattedFOrmatted
<br /> 59
<br /> Formatted 62
<br /> I P`
<br /> ''' FOITnat4ed 63
<br /> 64
<br /> Formatted 65
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