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(11gericy use unly/ ams plan n een evte an Approved U Approved With Conditions LJ Disapproved Local Agency Signature: D16 Comments or Special Conditions: UPCF UST Monitoring Plan — Page 2 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 p!jor,to installing or modifying monitoring equipment, (Note: Numbering of these instructions follows the data element numbers on the form.) V1.UDC MONITORING—Check the appropriate box(es)to describe monitoring of UDC systems covered by this plan. 490-54a. MONITORING OF THE UNDER DISPENSER CONTAINMENT—Indicate the method used for UDC monitoring.UDC MONITORING METHOD(S)—Check the appropriate box(es)to identify all required methods used for monitoring the area(s)beneath the dispenser(s). Check item 490-54a-I if the UDC is monitored by a leak sensor connected to a continuous monitoring console with audible and visual alarms. Check item 490-54a-2 if the UDC is monitored by a mechanical device that shuts the dispenser's shear valve when liquid in the UDC lifts a leak detection float.Check item 490-54a-3 if the UDC is monitored by a stand-alone leak sensor that is not connected to a continuous monitoring console.If no dispensers are installed(e.g.,emergency generator tank system), check item 490-54a4 and skip to Section VIT. Check item 490-54a-5 if the UDC is monitored by other methods. 490-54b.SPECIFY—If 99"Other" is checked, describe other method used. SPECIFY— If item 490-54a-99 is checked, enter a brief description of the other UDC monitoring method(s)used. If more space is needed,use Section X. Be sure to clearly describe monitoring method(s)and frequency. If VI-1-I,Vi-i-2 or VI-1-3 or VI-1-99 is checked,complete 490-55 to 490-64b. 490-55. PANEL MANUFACTURER—Enter the name of the manufacturer of the monitoring system control panel(console). If there is no control panel(e.g.,only an electrical relay box is installed)leave this space blank.LEAK MONITOR MANUFACTURER—If item 490-54a-I is checked,enter the name of the manufacturer of the monitoring system control panel(console). 490-56. MODEL#—Enter the model number for the monitoring system control panel(console).If there is no control panel(e.g.,only an electrical relay box is installed)leave this space blank.MODEL 4—If item 490-54a-I is checked,enter the model number for the monitoring system control panel. 490-57. LEAK SENSOR MANUFACTURER—Enter the name of the manufacturer of the sensor(s).LEAK SENSOR MANUFACTURER—If item 490-54a-I or 490-54a- 3 is checked,enter the name of the manufacturer of the sensor(s).,If more space is needed,use Section X. 490-58, MODEL#(S)—Enter the model number of the sensor(s)installed.If additional space is needed,use Section X.MODEL 4(S)—If item 490-54a-I or 490-54a-3 is checked,enter the model number for each type of sensor installed.If more space is needed,use Section X. 490-59. DETECTION OF A LEAK INTO THE UDC TRIGGERS AUDIBLE AND VISUAL ALARMS. Indicate Yes or No.WILL DETECTION OF A LEAK INTO THE UDC TRIGGER AUDIBLE AND VISUAL ALARMS?—Check Yes or No. 490-60. UDC LEAK ALARM TRIGGERS PUMP SHUTDOWN—Indicate Yes or No.WILL UDC LEAK ALARM TRIGGER PUMP SHUTDOWN?—Check Yes or No. 490-61. FAILUREIDISCONNECTION OF UDC MONITORING SYSTEM TRIGGERS AUTOMATIC PUMP SHUTDOWN — Indicate Yes or No.WILL FAILURE/DISCONNECTION OF UDC MONITORING SYSTEM TRIGGER SHUTDOWN?—Check Yes or No. 490-62. UDC MONITORING STOPS THE FLOW OF PRODUCT AT THE DISPENSER—Indicate Yes or No.WILL UDC MONITORING EQUIPMENT STOP THE FLOW OF PRODUCT AT THE DISPENSER UPON LEAK DETECTION?—Check Yes or No. 490-63, UDC CONSTRUCTION—Indicate if the construction of the UDC is single-walled,or double-walled.UDC CONSTRUCTION—Check the appropriate box to indicate whether the UDC has single wall or double wall construction.if you check item 490-63-1,skip to Section VII. 490-64a. DOUBLE-WALLED INTERSTITIAL SPACE MONITORING—Indicate what is used to monitor the interstitial space.UDC INTERSTITIAL SPACE IS—If you check item 490-63-2, check the appropriate box to describe the type of vacuum/pressure/hydrostatic(VPH) monitoring provided for the UDC secondary containment. 490-64b. LEAK WITHIN THE SECONDARY CONTAINMENT OF UDC TRIGGERS AUDIBLE AND VISUAL ALARMS—Indicate Yes or No.WILL DETECTION OF A LEAK IN THE UDC INTERSTITIAL SPACE TRIGGER AUDIBLE AND VISUAL ALARMS?—If you check item 490-63-2,check Yes or No. VII.PERIODIC SYSTEM TESTING 490-65. VII-I ELD TESTING—Check the 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 single-wall component and is located within 1,000 feet of public drinking water well). ELD TESTING—Check this box if the SWRCB has notified you that you must performperiodic Enhanced Leak Detection(ELD).You do not need to check this box if you need toperform one-time ELD testing(e.g.,post-installation testing) 490-66, TESTING OF SECONDARY CONTAINMENT COMPONENTS EVERY 36 MONTHS — Check the box if you have secondary containment that requires testing.SECONDARY CONTAINMENT TESTING— You must check this box and provide periodic testing if you have any UST system secondary containment components that are not exempt from testing because they are monitored by a continuous vacuum/pressure/hydrostatic monitoring system. 490-67. SPILL BUCKET TESTING—Check the box if you have spill buckets.SPILL BUCKET TESTING—You must check this box and provide annual testing of all UST fill spill buckets. Vill.RECORD KEEPING 490-68. Vill RECORDKEEPING— Indicate which monitoring and equipment maintenance records are maintained for this facility.MONITORING/MAINTENANCE RECORDS—Check the appropriate boxes to indicate UST records kept for the facility. IX.TRAINING 490-69a. IX TRAINING STATEMENT—Check the box to verify that the statement is true. REFERENCE DOCUMENTS MAINTAINED AT FACILITY—Check the appropriate boxes to describe reference documents maintained at the facility. Note that the first two items on the list must be kept at the facility.Check the box for item 490-69a to indicate that personnel with UST monitoring responsibilities are familiar with relevant reference documents.Check the appropriate boxes for items 490-69b through It to identify reference documents that are maintained at the facility.Note that items 490-69b and c are mandatory. 490-69b. MONITORING PLAN:Indicate that this plan is kept as a reference document. 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 document. 490-69e. CA UST LAW—Indicate that this is kept as a reference document. 490-69f ST ATE WATER RESOURCES CONTROL BOARD(SWRCB)PUBLICATION— "HANDBOOK FOR TANK OWNERS—MANUAL AND STATISTICAL INVENTORY RECONCILIATION":Indicate that this is kept as a reference document. 490-69g.SWRCB PUBLICATION:"UNDERSTANDING AUTOMATIC TANK GAUGING SYSTEMS":Indicate that this is kept as a reference document. 490-69h.OTHER—Indicate that other reference documents are kept. UPCF UST-D(12/2007)-6/7 www.unidocs.org WE IN