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(Agency Use limy) This plats has bm reviewed [] Approved With Conditions G Disapproved Local Agency Signature Date. Comments at Special Conditio UPCF UST Monitoring Plan — Page 2 Instructions Complete a separate UST Monitoring Platt 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. Picric note that your Local agency may require you to obtain approval 9dor 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 far UDC monitoring. 49044b. SPECIFY - If 99,uth r" is checked, describe other method used. if VG 1-1, VI- 1-2 or Y1-1,3 or V1-1-99 is checked, complete 490-55 to 490 -bob. 490-55. PANEL MANUFACTURER- Enter the name orthe manufacturer of the fromtorim system control panel (console} If there is too conhol panel (cg-, only an electrical relay box is installed) leave this space Mark onI an electrical relay box is installed) leave 490-56. MODEL 4 - Enter the model number for the monitoring system oonttltt }ratter (mttsoteJ if theta is 1n' eclat! panel (e.g.. Y this space blanL 490-57 LEAK SENSOR MANUFACTURER - Enter the name of the manufamner tribe sensor(s). 490 -SR. MODEL N(S) - Enter the model number of the sensors) installed_ If additional space is needed, am Seclim 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. 49061. FAILURE/DISCONNECt70N OF UDC MONITORING SYSTEM TR GGERS AUTOMATIC PUMP SHUTDOWN - indicate Yes or No. 49(162, UDC MONITORING STOPS THE FLOW OF PRODUCT AT THE DISPENSER - Indicate Yes or No. 490.63. UDC CONSTRUCTION - Indicate if the construction of tate UDC is smill' Adlcd, or double' -walled' 490-64a. DOUBLE -WALLED INTERSTITIAL SPACE MON17TORING - Indicate what Is used to mmtitor the interstitial space - 490 -64b. LEAF: WITHIN THE SECONDARY CONTAINMENT OF UDC TRIGGERS AUDIBLE AND VISUAL. ALARMS - Indicate Yes or No aslttre 490-65. Vim ELD TESTING- Check the box if you have him notified by the Staff Water Rew"I s Control board (SWRCB) that the UST(a) this by P� subject to Erdmoed Leak Detection Requirements (i.c., UST has any single -scall c+tneponent and is located within l •n'0 Ret of a public drinking water weft 490.66, TESTING OF SECONDARY CONTAINMENT COMPONENTS EVERY 36 MONTHS- Check the box if you have secondary containment that rcguites testing, 490-67. SPILL BUCKET TESTING - Check the box it you have spill buAW 49068. Vitt RECORDKEEPING - Indicate which monitoring and equipment mair�aance records are nusintairted for this facility. 49t169a IX TRAINING STATEMENT - Check the box to verify that the stateneai is arse. REFERENCE DOCUMENTS MAINTAINED AT FACILITY - Check the appropriate boxes to describe refuremce documents matntffined m the Ikcility. Noe that rhe first two items on the Itst IlM be kept m the facility. 490696. MONITORING PLAN: Indicate that this plan is" as a referent docufficat 490.69c. OPERATING MANUALS FOR ELECTRONIC EQUIPMENT: Indicate that this plan is kept as 1 reference document, 490.694. CA UST REGULATIONS - Indicate that this is kept as a reference document 490-69e. CA UST LAW - indicate that this is kept as a mfem= ducmnau- 490-69f. STATE WATER RESOURCES CONTROL BOARD (SWRCB) PUBLICATION - "FIANDBOOK FOR TANK OWNERS -MANUAL AND STATISTICAL INVENTORY RECONCILIATION"- indicate (he this is kept as a reference document. 490.698. SWRCB PUBLICATION: "UNDERSTANDING AUTOMATIC TANK GAUGING SYSTEMS"_ Indicate that this is kept as a rcfenrtce document. 490.69h. OTHER - indicate that otter reference documents am kept. 490d69i. SPECIFY - If"O7i{ER" rs checked, enter abrief description of the other doemreutt(s) maintained at the facility if additiortaf space is needed,see Suction X. 490-70. DESIGNATED OPERATOR TRAINING - Check this boa to verify the the smtentem is true. 490.71. COMMENMADDIfIONAL INFORMATION - Make additional co mrent$ or you may and identify the number of additional pages of irafotmmhat to will he any additional UST system rmutormg-rdst d information' (e.g.. additional information required by your total agency). Attach any monitoring top that you will 6e ruing for the monitoring of your tank system m maintenance attar this guru 490-72. NAME - Enter the name ofthe person who routinely coodutcts the monitoring and 041010=1111 490-73. TITLE - Enter the title of the person, meet maintenance under this plan 490-74. NAME - Enter the tent of the second person, if applicaishc, who routinely conducts the �mtoring and equipment 490-75. TITLE - ENer the title of the second person. esurt OWNER/OPERATOR SIGNATURE - Ttx The tank owdoperatot, facthty ownertoperstor, or an authorized Leprtative of the owner shall sign in the space provided. This signature certifies that the signer believes that all inforination submitted is IM wes¢ate, and complete, and that the training program specified in Section tX has beam imptemomed ortzed 490-76. REPRESENTING - Check the appropriate box to indicate whether the signer is the UST owredoperawr. the UST facility owmedoperator- or an and representative of the owner. 490.77. DATE - Euler the date the plan was siymed. 490-79. APPLICANT NAME - Print or type the name of the person ugmusg the plan 490-79. APPLICANT TITLE - Enter the title of the person signing the Rlam UPCF UST -0 (I V=17) - 414 www.uwldocs erg