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(Agency Use Only) This plan has been ed and y pproved ❑Approved With onduions f Local AFerrcy Signature: t' ld%riitM: Date. - Comments or Special Co i UST Monitoring Plan=Page 2 Instructions Complete a separate UST Monitoring Plan for each UST monitoring system at the facility. This fortn must be submitted with your initial LIST 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.) 490-54a.MONITORING OF THE UNDER DISPENSER CONTAINMENT-Indicate the method used for UDC monitoring. 490-54b.SPECIFY-11`99"Other"is checked,describe other method used. If VI-1-1,VI1-2or VI-1-3 or VI-1-99 is checked,complete 490-55 to 490.64b. 490-55, PANEL MANUFACTURER—Enter the nave of the manufacturer of the monitoring system control panel(console). If there is no control pastel(e.g.,only an electrical relay box is installed)leave this space blank. 490.56: MODEL d- 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 blank. 490.57• LEAK SENSOR MANUFACTURER—Enter the name of the manufacturer of the sensor(s). 490-58. MODEL#(5)—Enter the model number of the sensors)installed.tfadditionat space is needed,use Section X. 490-54: DFTECTiON 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- tmficate if the construction of the.UDC is single-waited,or double-walled. 490-64a.DOUBLE-WALLED INTERSTITIAL SPACE MONITORING Indicate what is used to monitor the interstitial space. 490-64b.LEAK:WiTHIN THE SECONDARY CONTAIMENT OF UDC TRIGGERS AUDIBLE AND VISUAL ALARMS-indicate Yes or No 490.65. VII-1 ELD TESTING;-Check the box ifyou 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 urn public drinking water well). 490-66. TESTING OF SECONDARY CONTAINMEW COMPONENTS EVERY 36 MONTHS-Check the box ifyou have secondary containment that requires testing. 490.67. SPILL BUCKET TESTING-Check the box ifyou have spill buckets. 490-6ga-h.Vlll RECORDKEEPING-ludic4te which monitoring and equipment maintenance records are maintained for this facility. 490.69a IX TRAINING SFA N 1`-Ctteck 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 ill be kept at the facility. 490-69b. MONITORING PLAN: Indicate that this-plan is kept as a reference document. 490-69c.OPERATING MANUALS FOR:ELECTRONIC EQUIPMENT:Indicate that this plant is kept as a reference document. 490-69d. CA UST REGULATIONS-Indicate that this is kept as a reference document. 490-64e. CA LIST LAW-Indicate that alai is kept as a reference document. 490-64f.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."UNIDERSTANDING AUTOMATIC TANK GAUGING SYSTEMS":Indicate that this is kept as a reference document. 490-69h.OTHER-indicate that other reference documents are kept. 490-69i: SPECIFY-rf"OTHER7 is chocked enter a briefdescription of the other document(s)maintained at the facility.If additional space is needed,see Section X. 490-70. DESIGNATED OPERATOR ING-Check this box to verify that this statement is true. 490-71. COMMENTS/ADDITIONAL INFORMATION—Make additional comments or you may attach and identify the number of additional pages of information to describe any additional UST system monitoring-related information(e.g..additional information requited by your local agency). Attach any monitoring logs that you will be using forthemonitoringofyour 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 the tidevf the person. 490-74 NAME'-Enter the name ofihe second person,if applicable,who routinely conducts the monitoring and equipment maintenance under this plan. 490-75. TITLE- Enter the title cof the accord person: OWNER/OPERATOR'SIGNA —The tank owner/operator,facility owner/operator,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 owner/operator,the UST facility owner/operator,or an authorized representative ofthe owner: 490-77. DATE'—Enter the date the plan was signed. 490-79. 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)4/4