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BCE#14573 (4g,wey use fy) `sp edEl Apprw4ed With Cajq Local Signatum Comments or Special Conditions. UST Monitoring Plan—Page 2 Ins coons 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 r to installing or modifying monitoring equipment. (Note: Numbering of these instructions follows the data element numbers on the form.) 490-541,MONITORING OF THE UNDER DISPENSER CONTAINMENT-Indicate the method used for UDC moni 490-54b.SPECIFY-If 99"Other is checked,describe other method used If VI-1-t,VI-1-2 or Vl-1-3 or VI-1-99 is checked,complete 4W55 to 49 430-55. PANEL MANUFACTURER-Enter the name of the manufacturor of the monitoring system control panel( to). If is no control (e.S„Daly ase cal relay box is' ed)leave Us space blank. 490-56. MOD - Enter the model number for the monitoring system control panel(console),If dm is no control panel(e-&.only an electrical relay box is< led)leave this space blank. 490-57. LEAK SENSOR MANUFACTURER-Enter the name of the manufacturer ofthe or(s). 490-5s. MOD o(S)-Enter the of the s)installed,Ifadditimal space is needed,use Section X. 490.39. DETECTION OFA LEAK WM THE UDC TRIGGERS AUDIBLE AND VISUAL ALARMS. Indicate Yes or No 490-0 UDCLEAK ALARM TRIGGERS PUMP SHUTDOWN- Indicate Yes or No 490-61. FAILUREIDISCONNECTION OF UDC MONITORING SYSTEM AUTOMATIC PUMP S -Indicate Yes or No 4 MONITORING STOPS THE FLOW OF PRODUCT AT THE DISPENSER-Indicate Yes or No. 4 CONS U ON- 'catt if the don of the is s' c- ed,or bio- ed. 49044a.DOUBLE-WALLEDINTERSTITIAL SPACE MONITORING-Indicate what is used to monitor the interstitial space. 490-64b.LEAK WITHIN THE SECONDARY CONE NT OF UDC TRIGGERS AUDIBLE UAL ALARMS-Indicate Yes or No 4 -1 ELD TESTING-Chock the box if you have be=notified by the State Water Resources Control Board(S )that the UST(s)covered by this plan is/are subject to Enhanced Leak Detection Requirements(`Le.,UST has any s' o-walt component and is located within 1,000 feet ofa public drinking water well). 4 G OF SECONDARY CONTAINMENT COMPONENTS EVERY 36 MONTHS-Check die box if you have secondary containment that requires testing. 490-67. SPILL BU -Check the box if you have spill buck 4 a-b PIING-Indicate which monitoring and equipment maintenance records am maintained for this facility. 4 EX TRAINING STA -Check the box to verity that the statement is true. REFERENCE DOCUMENTS MAINTAINED AT FACILITY-Check the appropriate boxes to describe reference documents maintained at the facility. Nate that the rim two item an the list MRS be kept at the facility. 490-69b. MONITORING PLAN:Indicate that this plan is kept as a rcf 490-69c. OPERATING MANUALS FOR ELECTRONIC EQUIPMENT:Indicate that this plan is kept as a reference document. 490-69d. CA UST REGULATIONS-Indicate that this is kept as a reference documcm 49049c. CA UST LAW-Inficato that this is kept as a reference document, 4 f.STATE WATER RESOURCES CONTROL BO (S CB)PUBLICATION ION- -HANDBOOK FOR TANK OWNERS-MANUAL AND STATISTICAL INVENTORY RECONCILIATION-Indicate that this is kept as a reference documcni. 490-69S.SWRCB PUBLICATIOM"UNDERSTANDING AUTOMATIC TANK GAUGING SYSTEM":Indicate that this is kept as a reference d 4 OIndicate that other reference documents are kept. 490-69i. SP -If"O "is chocked,enter a brief'description of tltc other d t(s)maimaired at the facility.If additional is needed,we Section X. 490-70, DESIGNATED OPERATOR TRAINING-Chock this box to verify that this statement is true. 490-71. COM +ADDMONAL INFORMATION-Make additional comments or you may attach and identify the number ofadditional pages of' ion to describe any additionatUST mordt ° g-relr ted information(cg,additional information requiredby your locall agency), Attach any mortitoring logs that you will be using for the monitoring ofyour tank system 49D-72. N the name of the person who routinely conducts the monitoring and equipment t under this plan. 490-73. - Enter of the n. 490-74. NA of the socced pawn,ifalipticable.who routinely conducts the monitoring and equipment maintenance under this plan. 490-75. the title of the second licism OWNERIOPERATOR SIGNATURE-no tank ownertoperator,facility owner/opennor,or an attft&W representative of the owner shall sigh in the space Provided. This signature es that the signer believes that all information submitted is troo,accurate,and complete,and that the training Program specified in Section IX has been implemented. 490-76. REPRESENTING-Chock the appropriate box to indicate whether the signor is the UST ownerloperator,the UST facility owner/operator,or an authorized representative of the owner. 77. DA -Eater the date the plan was signed. 490-78. APPLICANT NAME-Print or type the name of the person signing the plan. 490-79. APPLICANT TITLE-Eater the title of the person signing the plan. UJPCF UST-0(I V2007)414