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01/31/2008 THU 15:45 FAX 2094683433 SJC EHD 0005/010 0 (Agency Use Only) This plan has been reviewed and: Approved improved With Conditions ..,, /� ElDisapproved Local Agency Signature: Date: � C�es Comments or Special Conditi s: UPCF UST Monitoring Plan — Page 2 Instructions Complete a separate UST Monitoring Plan for each Us'1' 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 approvalrp ion to installing or modifying monitoring equipment. (Note: Numbering of these instructions follows the data element numbers on the form.) 490-54a MON)TORING OF TI ll UNDER DISPL'NSLR coN IrAfNMENT - Indicate the method used for UDC mmnitoring. 490-541 SPECIFY - If 99 "Other' is checked, describe other method used. I f V t- I - I , V i-1-2 or V1-1-3 or V I-1-99 is crecked, complete 490-55 to 490.64b. 490-55 PANEL MANUFACTURER - L'ntcr 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 MODF'.!, n - tinter the model number for tine 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->7 LEAK SENSOR MANUI'ACTt1Rt32 "- Enter the name of the manufacturer of the sensor(s). 490-58 MODEL 1'(S) -- Enter the model number of the sensor(s) installed. If additional space is needed, use Section X. 490-50 DFIT4"r ION OF A LEAK INTO'n ni UDC TRIGGERS AUDIBLE AND VISUAL ALARMS. Indicate Yes or No. 490-60 UDC LI'Al, ALARM TRIGGERS PUMP SIIUTDOWN - Indicate Yes or No. 490-61 PAILUitlf/1)7,SCONNECTION Oi' UDC MONITORING SYSTEM TRIGGERS AUTOMATIC PUMP SHUTDOWN • Indicate Yesor No. 490-02 UDC MONITORING sTOPS'n fE PLOW OF PRODUCT AT TI -ll: DISPENSER - indicate Yes m No. 490-63. I IDC CONS"IR(JCT1ON - indicate il'lbe construction of the lJDC is single -walled, or double -walled. 490.64a. DOUBLF,-WALLED INTERSTiTIA1, SPACE MONITORING -" Indicate what is used to monitor the interstitial space. 490-64b. LEAK WITHIN THE SECONDARY CON-I'AINMI?,N-I' OF UDCTRIGGERS AUDIBLE AND VISUAL ALARMS - Indicate Yes or No. 490-65, VII -1 1 ,I) I'FSTING -- 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). 490.66. "ITSTING OF SLCONDARY CON'T'AINMENT COMPONENI'S EVERY 36 MON'T'HS - Check tine box if you have secondary containnmen£ that requires testing. 4904,7. SPILI BUCKF,I-TESTING - Check the box if you have spill buckets. 490.68. VIII RI:( ORDKEEPING - Indicate which monitoring and equipment maintenance records are maintained for this facility. 490-69a. IX'IRAINING STATEMENT - Check the box to verify that the statement is true. RITI,'Itl N(_T DOCUMP,NTS MAINTAINED AT FACILITY - Check the appropriate boxes to describe relbrence docnunews maintained at the facility. Note Ilia( file first two items on the list mus be kept at the facility. 490-69b. MONK ORING PLAN: Indicate that this plan is kept as a reference document. 490-69c. OPERA'PING MANUALS FOR ELECTRONIC EQUIPMLNI': indicate that this plan is kept as a reference document. 490.69d. CA L!S'!R I SGULATiONS - indicate that this is kept as a reference doeumutl. 490-69e. CA 1 IS .11 iAW - Indicate that this is kept as a reference document. 490-691'. S I ATL WATER RESOURCES CONTROL BOARD (SWRCB) PUBLICATION - "HANDBOOK FOR TANK OWNERS - MANUAL. AND STA TISTFCAL INVENTORY RECONCILIATION": Indicate that this is kept as a reference document. 490-69g. SW R('13 PUBLICATION: "UNDERSTANDING AUTOMATIC TANK GAUGING SYSTEMS": Indicate that this is kept as a reference document. 490-69h. CSf1IPR - Indicate that other reference documents are kept. 490-69i. SPF;( I1 Y If"OTHER" is checked, enter a brief description of tie other docunrent(s) maintained at the facility. Ifadditimlal space is needed, see Section X. 490-70 DI 11,I6NATI D OPERATOR TRAINING - Check this box to verify that this statement is true. 490.7! . (- 0MMFN IS/ADDITIONAL INFORMATION - Make additional comments or you may attach and identify the number of additional pages of inforration to describe ally Additional UST system monitoring -related information (e.g., additional information required by your local agency). Attach any monitoring logs that you will be using for the mm»toring of your tank system 490-71 NAME " Enter the name of the person who routinely conducts the monitoring and equipment mahuenance under this plan. 490-73. 111'Ll - i=nter the title ofthe person. 490-74 NAM 1 - under the Hanle of the second person, if applicable, who routinely conducts tine monitoring and equipment maintenance under this pian. 490-75- 1'117./. -- Fnier the title of the second pesos. OW NFR/OPERATOR SIGNATURE The lank owner/operator, facility owner/operator, or an authorized representative of the owner shall sign in the space provided. nifnes that the signer believes that all information submitted is true, accuate, and complete, and that the training program Specified ill Seetiotl iX has �: ,rrqlcu:ulted. 490-70 11,1 PRf-:SLNiINC, - Check the appropriate box to indicate whether the signer is the UST owner/operator, the LIST facility ownerloperator, or an authorized ll'lIi CSCtIi NIIVV ofthe owner. 490-77 PA 1 F. !Adler the date tie plan was signed. 490-78 APPLICANT NAME •• Print or type the nannc of the person signing the plan. 490-79 APPLICANT TITLE - Enter the title of the person signing the plan. UPCF l!ST-D (12/2007) - 4/4 www.unidocs.org