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(A e€az v t eP 019yy) This plat)has freen reviewed:anus' 3CApprtwed 0 Approves!With Conditions tt �]Distpfiri�e d
<br /> E < f Agcnc�4iarwouie ......_ _'..'......_ Data: -
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<br /> Corr anent" ar aptecisE CnncEitte rs:
<br /> UPCF UIS` ' NIauituring Plan — Page 2 Instructions
<br /> Coniploc a separ.Ete US F Monitoring Flan for cath I,S I monitoring systetn at£Etc facility. this form muse be submitted with your initial UST'
<br /> OTACIatling Person Application and +Arthro 0 days of changes in the inf'onnati(An it writaains. Please nct€e that ye)ur haat agency trtay require Ycyu to
<br /> utnaua aplrrcrtatl rtctr tat irist ilirag ur flit cfi1:4'itag tricynittiring cxTuipnlcne. f C>ts: 'Surnbcring of thele instructions tolli>%ks(he:data elelnent nuttibers tett
<br /> the ibrm.)
<br /> 490-541 'b;(3N 1"IORIN6 0f, 11Eh t,dl)1 1{(?iSFENSI R£'(7NI 41N y1E:N 1 Irtiicat €hit methr�i t sc i!c r t lC}C'monitoring
<br /> dt(1_>4h. s"t:f"11`A' ff vv°Y)±het es chc,�d,de;Mrihc t`a9hr tr.etiod u�{.
<br /> t4 VI i-.1 of ',]-,-9v is cheekcd,complete 4lh)-55 to 49C*')(46
<br /> 4 3f1-Sg I'A'vp A�talN? I-V-11"RER Enter the numc o,the nnsnui�cttnretr E`tie mc;nrtorrng a}.ter control panel(eta?nsa?e)_ If there is no Conti zlI Panelfc._�.,only,an cicctrie.�ti
<br /> n n iA«z is nt ttiedt lea%C 01ts.spacc I'Link,
<br /> 440-�(, VOIN't_= h:an.er.re model s=aar;Pher&,r the monitoring system Control panel(consolcf-Ifthere is no control panel to„g.,ally aro elecrrwal re,ay Exec is,nstaneAEl'seac;e
<br /> tlars stxtcc hlw k.
<br /> ata}-c i€AK SE'NY)it M A''14 ACI RER Enter tIPe name of the alums facwrer of the srnsotAs).
<br /> 414)•5R. A h TfDi:.NSA Enter the mcafel numbea ot'Ahc scnsoris)inraalled.ffadditionrl space iA nee tui,use Section X.
<br /> ;cxi-a9, Let 7i C`I It)�3 t:71�A 1.1,ils INtt)t 1It t+1)C 1 iZlt rt,i1'I{ti r\1)[J 3l.E AND VISUAL ALARMS, 7ncf ea,e S'ea or No.
<br /> 41)O-(i0, t IX'TI_AKALARM IRKAi1::RISkIX11'`;#I(itI:9C>l N`hidwaleYes,(,wNo.
<br /> tcAF til_ t,,%I I t RI:iDiN(t)NNf( I R)N(:)I t DA. `•'IttM FORINCi SYSti h1 TR166FRS At IOM A I'1C I''t A11'S}'lt3'I'l;M3W`N-Indicate Yc.e or No.
<br /> 4440-62, t IX M, 0\1 1,ORlN(;',,[ Pti f IIf:Ft.0”CII [IRA WF • 'I-AT I HE DISPENSI'R lrttlrcate Ves or No.
<br /> 490-0, t IX (ONS t Rt�(I ION Indicate it the construction ofthe..UI7f. assingla-w-afled,'tr dOuble-walled.
<br /> 41,0-64j, f)r it JILL-WALLED INN HIS Cl HAL VACU MOINUC?RIN6 -lnd,catc%That is used tt,motwoi the iritersdAia,spzaJc:
<br /> 419-04h. I.PAK WII1l1N'lIII,SF(ONLDARY CON-1 AINI,111N I OF LDC FRIG FRS AUDIRLF AND VISUAL.ALARMS -Indicate Yew or No.
<br /> 410-65. A 11 E 1.1) 11 S i INTO Cheek the bo,<7f you hsvc bean nobfired Its tire State At'aler Rcsour€k Control Board(SWR('8)that the UST(s)cot cfed by This Is,are Wary
<br /> stthr t,tv'F:n Panc.W L.c ak I:k wetion Requirements(i.c.,UST has any"IrOe-wall cv mp ncant and is k sated within I,0(A)feet of a public rInnkrnt-r water A elb,
<br /> 490-i,6, I!1,IIN(:i(_)f 14f'0,N`DARY"CO1,`FAfNi11I,NFCOMPYNEN"ISFVLKY16.MON I'14S -CheckJvboxiCyouhavesecondarycon€ainmentthatrequirestesting.
<br /> 490-6(. Sf`1A l3t,CKL I IISIIN(A theck the bov,fyoutersespillbwskets.
<br /> gtl..6#i V'1i1Riau)Ri7KVf-l'INO Indtcatccehichinvaailoringand equipment ntamenanccrcc:,anisarcmaintained it'arthis!acthty.
<br /> iX1R:AINIA(iSIAIINIFNI -('heck the b,etotivrfathat taacstatetecntistitle,
<br /> R .f R(_N(t'Cx X'UAlFNTS MAINI-AIN IT<A I-FACII 11 V t.?tcck 0w approprwte boxes to describe retcresu:e documents maintatned at the facility Note that the
<br /> iu-t;leo i,.cros>n ate lis(ijW be kept at the haeihny.
<br /> 490-(>a) %,I(IV ONlt^6 PLAN Indicate that this plan is kelt as a reference document,
<br /> 111 RA PING;M ANt=r1LS FOR ELFC-IRONIC I:Q i INII.NT:Indicate that this plan is kept as a rrefetcrive dix:umeni.
<br /> s a_t3 ata € i"N i It H,p i.;A 1 fi),tvti--indicate that al'us is kept as a tct'creece c.0cuaent.
<br /> 4=XI.99r. A Ai:SI I-A\k Ins1i.ateihwdni, skept;asu letelencedcxument.
<br /> 4<kl_hcpp: S1,,A hi WWI ER RESOURCES CONTROL BOARD(SWRC B1 PUBLICATION "HANDBOOK FOR'!-ANK OWNERS MANUAL ANID
<br /> S€'AT`J.S—I ICAL INVEN'TOR t"RECONCILIA-ZION lndicatc that this is Tcev as a rClerc'rice documet.
<br /> 49tr-69o, IS RCB P('BLIC'ATION:-'UNDFRSTANDlNGAUTOMATIC t'ANKGAUGINGSY'S'TEMS Indicate that this iskept asitr€fe(ercedeCen^ent.
<br /> 4<)t3 49h 0I HER €ndicaw that rather tefiirvnee carxu-nests are kept,
<br /> 497-t,,)i. Sill(11`y 11—01 y1 i4FR-is chcc'kcd,canter a brief'dtscripiio n ofthc udrer doeviric<a(s)mauttatncd at the facility,It'j4ditional space is aceded,see Section X.
<br /> l)1 4It:;N-1 CI I)OPERA IC)R IR AININ6 t heck this hog;u rtkliFeat this etate:ncnt r?true.
<br /> ?M 19t'.ti 14 ADLII IK)N Af_INFORMATION iATION- Make additional commcros 3_-you may attach and identify the namber of addnional pages of in fx'trmation u,describe
<br /> aup saddluolwl t,s I"")"twin moa;€t ung-rctlate.I intermation(,c.g-addioonal inl6i-manon required by s,Iur local a&encyy Attach any monitoring toffs that yu¢; i,°ill he
<br /> die m-nf"Ting"I e¢snr taftk s,Ystem
<br /> p eta-�z. -S_S11I;
<br /> Inter tart name<E;F,c per ,n tis hc;r tutincly cnnduct.a the:,Ilonito ing and cquipowift taaintenance under this plan-
<br /> ivt)-7;_ I i t I EInner tha title"'the pear'son.
<br /> -4 ?-1 1?tl= I mvi,the haeme,o€'the rev 1n;.i person,if 3pphcablc,e%ho row mck conducts the monitra.n-g And equip rent attaint ante under this 1,Ian.
<br /> '490-``i. I i I€E - Litter tic title o4,the second reNon.
<br /> (AA,NI R-'£)I'I R>,T(7R !E,A,A'7 i'RE'_. the tarn owner ,opciator.I€ [Eity ttuner-operata; oran authoriziel represmiative of the framer shall sign in the sg au previdui.
<br /> I his srgr,atutc ccrtaics that the signer txshoes that aft Information stibmflAcd is r~gn,accurate,and eomplLw,artt that the training program Ncified in Seetion has has
<br /> Ixc'ri;3itpltC i}Pl"[efG`(i.
<br /> 490_76. RI PR1 SFNTIN( - (;heck the: apAxopriaie hot io attd€caste .thcbcr the signer is the t-Sl ouner4Pperaker, the US1 titcHity owntrropctwor. or an authorizaxl
<br /> re,tcscntrttives)t the imner-
<br /> 4r>t- D A P1, I'ntty the cletc the plan se as Ii rated.
<br /> 40x)-'g_ ,ANPLK %N'l NA1,11 -Print,,,r t}pctthc aunty o?dw tmrsert sig ring the plat,.
<br /> 490,7t)_ APE'1 It.AN'l l 1 I I E'.- Enter EPFC r tic e?tf:e pctuut 6iLn1 rr a e pEan
<br /> UPCIF t'S4 ID$33t #7) 4,4
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