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(Agency Use Only) This plan has been reviewed and: Approved ❑ Approved With Conditions ❑ Disapproved Local Agency Signature: .t/LL Gr'1�`''�-� Date: to 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 prior to installing or modifying monitoring equipment. (Note: Numbering of these instructions follows the data element numbers on the form.) V1. UPC MONITORING Cheek !he appwpFiate box(es4 to describe FnenitoFing of JJDC systems eavered by this plan. 490-54a. MONITORING OF THE UNDER DISPENSER CONTAINMENT - Indicate the method used for UDC monitoring. UD"ONITORING MET! 10D(8) Cheekthe appro PF Fate box(es) to all4equ+red-'mm }ser(s). Cheek-ite+}}-490->4a44f the r jDC :toff + }}v a leak sensor eanneeted to a}ne+nitofir}g co+Isola with-ai490 54x-2 &4lwe -LASE=is'-nionitored-4)" meehanical devioe thatshms the dispeRSeF'S ShOaF N'a!Ve when liquid in the UPC lifts a leak deteciion float. Ch % tem 490 44a 3 ifthe UDC is monitemd*y a stand alone !@all sensor iliat is nel eonneeled to a contiRUOUS 1110flilff4le CORS01e. if R0 dilipeflSeFS We 4istalled (e.g., b - 490-54b. SPECIFY - If 99 "Other" is checked, describe other method used. SPL'C-i1�---Y--l4-'' te*v-49(Ia4a-99--is chewked;-t3nter�-betel deesc{'iptwn a€ thcti+ther Flt e}o+}iteri+rg }»ethod(s) used.. If+nore spaeeis needed. use See6on X. Be sue ure to Clearly describe monits+ri.ng.+}u�th<>dfs�ai}ci-trc�tuene� If VI -1-1, VI -1-2 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. 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 MODEL # Ifitefn49054a 1 is eheraked, entef4he model number fef the ffi()Hitffifig S)'StOffi GOR401 Panel. EAP -SENSOR MANUrACTURP lfiie.., 490 c4.. l ,.4on c4.. 490-57. LEAK SENSOR MANUFACTURER -Enter the name of the manufacturer of the sensor(s).=-�,-�, �< 3 is uheokca is-n0tK4ed--uie,Sect4"-X-. 490-58. MODEL #(S) - Enter the model number of the sensor(s) installed. If additional space is needed, use Section X.MODla:-4S4 is each -type -of -sense instal led. if more space is needed, use S eet ii X 490-59. DETECTION OF A LEAK INTO THE UDC TRIGGERS AUDIBLE AND VISUAL ALARMS. Indicate Yes or No.W11 i nrTF-GTI N nr A l r n v 11,40 444h UPC TRIGGED AUP 114 I=F AND VISUAL ALARMS? Chee! vee •,-fir,.. 490-60. UDC LEAK ALARM TRIGGERS PUMP SHUTDOWN - Indicate Yes or No.W41,bnC inn v ALARM Tn T > n-- � - SHUTDOWN n . No': 490-61. FAILURE/DISCONNECTION OF UDC MONITORING SYSTEM TRIGGERS AUTOMATIC PUMP SHUTDOWN - Indicate Yes or No.'W'ILL, E411 1 r°,- .a< nr�''r r- 441*I13'fiIO.N..0 1-4i IYInx,rTnurnv cvc rcnA Tvir:r_r,u ecru4DOWNk Y '?--Cbeces OF No 490-62. UDC MONITORING STOPS THE FLOW OF PRODUCT AT THE DISPENSER - Indicate Yes or No.W11.4, UPC MONITORING cnr imnnrrrr eTr In cur rr OW OF P OD CT ,n T THE DISPENSER UPON LEAK DETECTION? ChOek yes eF , 490-63. UDC CONSTRUCTION - Indicate if the construction of the UDC is single -walled, or double -walled. indieat oal3le *H-c-enstfuc4ien-lf-,ou eheek item 490 ;3 1 z skip to Section -V-11.; 490-64a. DOUBLE -WALLED INTERSTITIAL SPACE MONITORING - Indicate what is used to monitor the interstitial space. UDG4NT4-iM. I'444AL-SIzA E is - if you Ghee "'tem -490 i�-provlded-for'4he-W)", econdafy eentainment. 490-64b. LEAK WITHIN THE SECONDARY CONTAINMENT OF UDC TRIGGERS AUDIBLE AND VISUAL ALARMS - Indicate Yes or No.WILL DETECTION Or.. A LEAK Pi THE UDC TITIA!, 8 PAC -F TRIGGER AUDIBLE AND VISUAL ALARMS? it'vea (sheek item 190 63 2, 6he6k Yes OF NO. �,�I-E� p.FRFnnr�• cvc•rs�� rccrr�i• . 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 a public drinking water well). ELI) 1=1;S I4N(---G4wGk ' 4ed-you-that--you--ret : _._.._ - Fx4:01}-(E-L-U; Ya++ da not' -need to -check -this box if you need w pe*--�qfm one time F1,I) tesliflg (e -g_ 490-66. TESTING OF SECONDARY CONTAINMENT COMPONENTS EVERY 36 MONTHS - Check the box if you have secondary containment that requires testing. 8 P. GON PARY CONT-ADA4ENT TESTING You must cheek this boN and pfoNide PeFiodie testing ifyoH have any UST SysteFA ,Ocofid c 490-67. SPILL BUCKET TESTING - Check the box if you have spill buckets.SPILL BUCKET TESTING You..{}}ust'chcwk_tl}is..l+ox an<}L�r�yd�-ann++aj Ceti ng of all L-1,S'l= t+l€ spill btwkets V111. RECORD KEEPING 490-68. VIII RECORDKEEPING - Indicate which monitoring and equipment maintenance records are maintained for this facility. MON NITORIN(j44 .iNTE ANIGh 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. i ' re familia with FRIevani . C4}e k 4h8 u�"� *4f 4o-KWnti€y-reteren doeume t= tstned at t#+e 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. STATE 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