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(Agency Use Only) This plan has been viewed d: Approv ❑Approved With Conditions ❑Disa oved Local Agency Signature: Date: Comments or Special Conditions: UPCF UST Monitoring Plan Page 2 Instructions _U_Dc- --------- ---------- -- -- - - -- ---- --- -- ------------------ ------ ----- -- -------------------------------------------- Vl.UDC MONITORING Check the appropriate boxes)to describe monitoring of UDC systems covered by this plan. 490-54a. 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-1 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 490-54a-4 and skip to Section ViI. Check item 490-54a-5 if the UDC is monitored by other methods. 490-54b. 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. 490-55. 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# If item 490-54a-I is checked,enter the model number for the monitoring system control panel. 490-57. LEAK SENSOR MANUFACTURER If item 490-54a-1 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) 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. WILL DETECTION OF A LEAK INTO THE UDC TRIGGER AUDIBLE AND VISUAL ALARMS? Check Yes or No. 490-60. WILL UDC LEAK ALARM TRIGGER PUMP SHUTDOWN? Check Yes or No. 490-61. WILL FAILURE/DISCONNECTION OF UDC MONITORING SYSTEM TRIGGER SHUTDOWN? Check Yes or No. 490-62. WILL UDC MONITORING EQUIPMENT STOP THE FLOW OF PRODUCT AT THE DISPENSER UPON LEAK DETECTION? Check Yes or No. 490-63. 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. UDC INTERSTITIAL SPACE IS If you check item 490-63-2, check the appropriate box to describe the type of vacuum/pressure/liydrostatic (VPH) monitoring provided for the UDC secondary containment. 490-64b. 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. V11.PERIODIC SYSTEM TESTING 490-65. ELD TESTING Check this box if the SWRCB has notified you that you must performetp iodic Enhanced Leak Detection(ELD).You do not need to check this box if you need to perforin one-time ELD testing(e.g.,post-installation testing) 490-66. 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 You must check this box and provide annual testing of all UST fill spill buckets_ - ---------------------------------------------------- ----------------------------------------- ViiI.RECORD KEEPING 490-68_ MONITORING/MAINTENANCE RECORDS__Check the appropriate boxes to indicate_UST records kept for the facility--------------------------------- -1 X__. _______IX.TRAINING 490-69. 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 h to identify reference documents that are maintained at the facility. Note that items 490-69b and c are mandatory. 490-69i. SPECIFY If item 490-69h is checked,enter a brief description of the other reference documents maintained at the facility. 490-70. DESIGNATED UST OPERATOR You must check this box and have at least one Designated UST Operator Curently certified by ICC.Your Designated UST Operator(s)must perform and document monthly visual inspections of UST system components and provide required initial and annual refresher training _ for facility persoone L ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- X.COMMENTS/ADDITIONAL INFORMATION 490-71. You may use this section to describe any additional UST system monitoring-related information(e.g.,additional information required by your local agency). if using Section X as additional space for items required elsewhere in this plan,reference the item number(e.g., Item 490-33-Model 2468 and 3579 Leak Sensors ). X1.PERSONNEL RESPONSIBILITIES 490-72. NAME Enter the name of the person with ultimate authority for performing the monitoring activities and maintaining leak detection equipment covered by this plan.If more than one person has such authority,complete Item 490-74. 490-73. TITLE Enter the title of the person with ultimate authority for performing the monitoring activities and maintaining leak detection equipment covered by this plan.If more than one person has such authority,complete Item 490-75.If not,skip to Section XII. 490-74. NAME See instructions for item 490-72.If more than two people have such authority,note the additional names in Section X. 490-75_ TITLE See instructions for Item 490.73. If more than two people have such authority,note the additional names in Section X. ---------------------- Xii.0WNER/6PERATOR SIGNATURE The owner/operator shall sign in the space provided. This signature certifies that the signer believes that all information submitted is true,accurate, and complete,and that the training program specified in Section IX has been implemented. 490-76. REPRESENTING Check the appropriate box to indicate whether the signer is the UST owner/operator, the facility owner/operator, or an authorized representative of the UST owner. 490-77. DATE Enter 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 Enter the title of the person signing the plan. ------------------------------------------------------------- UPCF UST-D(12/2007)-616 www.nnidoes.org