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(Agency Use Only) This plan ass been rev' pproved ❑Approved With Conditions 0 Disapproved Date: Local Agency Si Comments or Spec" ndi UPCF UST Mon I itoring 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 orior to installing or modifying monitoring equipment.quipment. (Note: Numbering of these instructions follows the data element numbers on the form.) 490-54a, MONITORING OF THE UNDER DISPENSER CONTAINMENT-Indicate the method used for UDC monitoring, 490-54b.SPECIFY-If 99"Other"is checked,describe other method use& If VI-i-1,VI-1-2 or VI-1-3 or VI-i-99 is checked,complete 440-55 to 490-64b. an electrical 490-55, PANEL MANUFACTURER-Enter the name of the nmnufbctufer of the monitoring system control panel(console), Ifthere is no control Panel(e.g.,only relay box is installed)leave this space blank 490-56. MODEL#-Enter the model number for the monitoring system control panel(console)-If tyre is no control pawl(e.g.,only an electrical May box is installed)leave this space blank. 490-57. LEAK SENSOR MANUFACTURER-Enter the name of the nianuf8chm of the wwoqs)- 490-5& MODEL#(S)-Enter the model number of the sensor(s)installed.If additional she is needed,use Section X 490-5 9 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. 490-61. FAILURE/DISCONNECTION OF UDC MONITORING SYSTEM TRIGGERS AUTOMATIC PUMP SHUTDOWN-Indicate yes or No. 490_62, UDC MONITORING STOPS THE FLOW OF PRODUCT AT THE DISPENSER-Indicate Yes or No. 490-63. UDC CONSTRUCTION-Indicate if the construction of the UDC is single-walled,or double-walled. 490-64& DOUBLE-WALLED INTERSTITIAL SPACE MONITORING-Indicate what is used to monitor the interstitial space. 490-64b.LEAK WITHIN THE SECONDARY CONTAINMENT OF UDC TRIGGERS AUDIBLE AND VISUAL ALARMS-Indicate Yes Or NO 490-65. V11-I ELD TESTING-Check the box if You have been 00 1 tified by the State Water Resources Control Board(SWRCB)that am UST(s)covered by this plan is/are subject to Enhanced Leak Detection Requirements(i.e.,UST 16s any single-wall component and is located within 1,000 feet of public drinking water well). 490-66. TBTrING OF SECONDARY CONTAINMENT COMPONENTS EVERY 36 MONTHS-Check the box if you have secondary containment that requires testing. 490-67, SPILL BUCKET TESTING-Check the box if you have spill buckets. 490-68. Vill RECORDKEEPING-Indicate which monitoring and equipment maintenance records are maintained for this facility. 490-69a. IX TRAINING STATEMENT-Check the box to verify thaf,Ihe statement is true. REFERENCE DOCUMENTS MAINTAINED AT FACILITY-Check die appropriate boxes to describe reference documents maintained at the facility. Note that the first two items on the jig win g be kept at the facility. 490-69b,MONITORING PLAN.Indicate that this plan is kept as a reference doctiment. 490-69c.OPERATING MANUALS FOR ELECTRONIC EQUIPMENT.Indicate that this plan is kept as are 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 docianam. 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 490-69&OTHER-Indicate that other reference documents are kept ( tained the faci 490-69i, SPECIFY-If"OTHER7js checked,enter a brief ilescription of the other document(s)main at lity.Ifadditional she is needed,see Section X 490-70. DESIGNATED OPERATOR TRAINING-Check this box 0 verify that this statement is true- 490-71. COMMENTS/ADDITIONAL INFORMATION-make addition al comments or you may attach and identify the maratier of additional pages of information to describe any additional UST system momtoring4elated hiformation(C.&,a"unind information required by your local agency1 Attach any monitoring logs that you will be using for the monitoring of your tank system 490-72. NAME-Enter the name of the person who routinely conducts the monitoring and equipment maintenance under this plan. 490-73. TITLE-Enter die tide of the pawn. 490-74. NAME-Enter the name of the second person,ifapplicable,!who routinely conducts the monitoring and equipment maintenance under this plan. 490-75. TITLE-Enter the tide of the second Person OWNER/OPERATOR SIGNATURE-The tank owner/opendor,facility oww/opendor,or an authorized representative of the owner 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 ownedoperator, the UST facility ownedoperator, or an authorized representative of the 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(MW7)-414 www.uokkies.org