COMPLIANCE INFO_2012-2018 - Laserfiche WebLink

Home Browse Search

04/18/2013 11:50 2093344684 #5032 P.012 1020 ........... —�W Tlai 7—.7- g. ,4P, d d� .......... UZI ..... ...... p -M UST Mon1toring Plan—Page 2 Instructions Complete a separate UST Monitoring Plan for each UST monitoring"&- at ft facility. This farm must be submitted with your Wffial UST Oprating Permit Application and within 30 days of Changes in the information it 000taiS. Please note dmd your local fey may reqgre you to obtain approval pdff to in�or modifying monitoring eq4tnml, {Nate: Numboft of dime irmnictions Mows the d9a element numbm on the form-) 490-549.MONT1701113%ry OF THE UNM DISPENSER CON[TAINLMN'T•lodtaft doe mathod used for LMC wvo:uuvn& 490-54b,SPECIFY-If 99'Offie it dwakcd,describe other ac u*j If Yl-1-1,Yl-1-2 or VI-1-3 or VI-1-99 is dmk4*owoau 490-55 to 490.64b. 490-55. PANEL MANUFACTUREP-Erar tI*M=of the matut&etum oftba monjolmg M=comol PaW(comote) Ifthem Is no coft*l paod(c.&,ow y a elachiag re*bDx a ingallod)leave this space blank 490-56 MODEL Enter the model nm*u for the toonnomg*V01n ON"PHIMA(OMSDIC)lftb=Is DO 0010W P2ftl(c 9-Only an elfthWJ relay box is WWARed)km &i$ spaceblauL 490-57 LEAK SENSOR MANUFACTURER-Fift the am=ofthe ofthe se mor(s) 490-5&MODEL#(S)-Enter the moo mmber of the mmoc(s)inswW,Ifudditional space is needed,W Sedion)L 490-59 DETECTION OF A LEAK INTO THE UDC TRIGGeS AUDIBLE AND VISUAL ALARMS.ludicate Yes of No 490-60.UDC LEAK ALARM TRIGGERS PUMP SHUIDOWN- Indicate Yes or No 490-61.FAILUREIDISCON NECnON OF UDC MONITORDM SYS mho TRIGGERS AUTOMATIC PUMP SHVrDOWN-Ideate Ycc tx No 490-61 UDC LKWIORING MOPS THE FLOW OF PRODUCT AT THE DISPENSER-Indicave Yes orN*. 49W.7.UDC CONSMUCTXON-lu&c*eifthrcoututmofthe UDC issh6lo-wdhAordouble-%WM 490-64a.DOUBLE-WALLED INTMTMAL SPACE MONITORING-Indicate what is used to mfttor the hmmstitial spa= 490-64h LEAK WITHIN THE SECONDARY CCUTA54ENT OF UDC TRIGGERS AUDIBLE AND VISUAL ALARMS-Indicate Yer.or No 490"65. VII-1 EW MMJG-Cho&the box ifyou have been notified by the SUN WOW Rom=Coetrol Scud(SWRCB)00 the UST(s)oovaul by this pin Wart sutdect ID Enhanced Leak Ddgcfw Requwancats(ix,UST ha any single wan component and is I.DDO feet of pablic dralking water wall) 494-M TIESTIM OF SBCONDARY CONTAINMENT 001APON&M EVERY 36 MONTHS-0"the box ifyce have w=xlvy comilmmttha Mqum ftuta2g. 49"7. EMU BUCM TESTING,-Che&the box if you bane spill . 4�VM RECC)RINCEEPINQ-Indicaw wbwh mandoring god"pom umntmaum records am fimpUzoW forlhm&eddy 4904% IX TRA IRM STATEbONT-Chock the box to verify that fie swmmag is Mv. REFERENCE DOCUMENTS MAWrAINED AT FACILITY-Owithcapluvpriate boxesiD deawibe"fWcoccdommants ronntaivW at the hanity NoWskirt the fns me b=on the fin mmu be keo at Ow furft. 490-69b. MON17ORINGPLAN.Indicate that this pkm is kept as a refaeft*d9cutneaL 40049t, OPERATING MANUALS FORELBCMOMC EQUIPMWr:Ittelicaft that this plun Iskept as a refit"M doogmt. 490-69d CA UST RBGULA77ONS-Tftdioale that this is kept as a referoxv dommox 490-69c.CA UST LAW-Indicate tbot that is kqt ass,refermcc documeW 490-69f STATE WATER RESOURCES CONTROL BOARD(SWRCB)PMLICATION- -HANDBOOK FOR TANK OWNERS-MANUAL AND STATISTICAL INVENTORY RECONCILIATION-Indicate ft this is kept as a rcfim=domnent 490-ft SWRCB PUBLICATION:"UNDERSTANDING AUTOMATIC TANK GAUGING SYSTEMS" ludmk that thm is kept 3S.3 mhrc=&MMICK 490-M OTHER-bxbmft OW Ow refka=documents=kept. 490.6%. SPECIFY-If"GnMrisdmck4enwrgLbnddownpbw ofthe ollmdociam*t)—fimmodat the&ifity Ifaciftonal%=e is nee"we SoctkmX. 490-70 DESMNATEDOPE KATOR 7RAD4XNG-Check this box love*that this%amout is oft 490-71. COMMENTItADDITIONAL,INFORMATION-Mak.-addonal*oxum=ts or you may anaeb and xka*the manber ofaddiapnW pVm ofiefmmot,to ftm6e. any XWdOrAd UST q*mmonitm*-related taft-ation(e.g.additional intmution Mquited by your local apncy) Aftxbany M0Wtm*IWdrat you wiIIbcusing for the twut*ring ofymw tanks/St= 490-71 NAME-&4v the 5=*ofthe person who routia*condum the monswing and under this pbA 490-73.TIILE• 490-74,NAME-EakT the nam ofthe sc000d porw4 if applicable,who roucio*ootdoetu the mogitatag and quipulenj toniuftane,wKier this pbm 490-75 TITLE-Enterthetitle ofthe second paun OWNER/OPERATORSIGNATURE-The tmk ownedbpxal0r,1bv*ow=Jq=v2or,of anaulborind mptsuntativeofftowlMshall sign m ft SpWepwided 710 W30"Wfifift that 16a"Pa believes that QH iflf0mulim OWAMW is troke wm-zle,and complete,and that the tubing tram qxxifiad k SS Dc has been ftomentod. 490-76 REWSENTINe-Cbeck the Vp0paft box to indictee WhWff the 538M LS the UST owo=/operax,the UST fwlity ownedoperaW,of an m4borized representative ofthe owner. 490-77. DATE-Ebter the daft the plan was$iVk%L 490-78. APPLICANT NAME-Prid or type the unne of the pawn gigging the plan, 490"79. APPLICANT TITLE-Buter do tie of the pow siV*the plan UPCF UST-0(12CWn 414