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(germ y Use only) This plan has baa reviewed and: ❑Approved with C nditiona Local Agency Signature: CDMMCM Or Special L011111110118C t" UST Monitoring 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 approvalgro 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 CONT the used for UDC monitoring. Y I 490-54b.SPECIFf 99 is checked, other used. - If VI-1-1,VI-1-2 or VI-1-3 or VI-1-99 is checked.complete 490-55 to 4 490-55. PANEL MANUFACTURER-Enter the name of the manufacturer of the monaming system control panel(console). If there is no control panel(e.g.,only an electrical relay box is insedled)leave this space blank. 490-56. MODEL#- Enter the model nmaber for the monitoring system control Panel(awsole}If there is no control panel(e.g.,only an electrical relay box is inst lled)leave this space Wank. 490-57. LEAK SENSOR MANUFACTURER-Erterthe ofthe manuflictunnofthe s). 490.58. MODEL#(S)-Enter the model number of the s)instailled.If additional space is needed,use Section K 490.59. DETECTION OF A LEAK INTO THE UDC TRIGGERS AUDIBLE AND VISUAL ALARMS. Indicate Yes or No 490-60. UDC LEAK ALARM TRIGGERS PUMP SHUTDOWN-InduftYesorNo 490661. FAILURE/DISCONNECTION OF UDC MONITORING SYSTEMTRIGGERS 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 iftheconstnicamofthe UDC is ' walled,ordouble-wallea 490.64a.DOUBLE-WALLED INTERSTITIAL SPACE MONITORING-Indicate what is used to mmdtor 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 boat ifyou bare been notified by the state Water Resources Control Board(SWRCB)flat the UST(s)covered by this plan is/are subject to Enhanced Leak Detection Raluircroems(Le„UST has any single-wall component and is located within 1,000 fed of a public drinking water well} 490-66. TESTING OF SECONDARY CONTAINMENT COMPONENTS EVERY 36 MONTHS-Chap the box if you have secondary containment that requires testing. 490.67. SPILL BUCKET TESTING-Check the box if you bane spill 4 VIII RECORDKEEPING-Indicate which mandomig and equipment imuntimence records are maintained for this facility. 490.69a DC TRAINING STATEMENT-Check the box to verify that the statement is truo. 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 ME be kept at the 490-69b. MONITORING PIAN.Indicate that this plan is kept as a reference document. 490.69e. OPERATING MANUALS FOR ELECTRONIC EQUIPMEN717,Indicate diet this plan is kept as a reference document. 490-69d. CA UST REGULATIONS-Indicate that this is kept as a reference documem 490.69e. CA UST LAW-Indicate that this is kept as a reference docamicuL 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. 490-691 OTHE31-Indicate that other reference documents are kept. 490-69i. SPECIFY-If"OTHER"is checked,enter a brief description of the other s)maintained at the facility.If additional space is needed,ser Section X. 490-70. DESIGNATED OPERATOR TRAINING-Check this box to verify that this mcmcm is tutu. 490-71. COMMENTS/ADDITIONAL INFORMATION-Make additional comments oryou may aftach and identify the number of additional any additional UST system monito' on(e.g, information pages of information Oto daaetuby Your local agency) Attach any monitoring logigs thwat 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 maintenanee under this plan. 490.73. TITLE- Enter the title of the person. 490-74. NAME-Enter the name of the sawed person,if applicable,who routinely conducts the monitoring and equipment naimeriance under this plash. 490.75. TITLE- Enter the tide of the second person. OWNER/OPERATOR SIGNATURE-The tank ownedoperalor,facility ownedoperator,or an authorized representative of die owner shall sign in the space This signature certifies that the signer believes that all infommtioa 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 owrer/openator,the UST facility owner/operator,or an authorized representative of the owner. 490.71. 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 tide of the person signing the plan. UPCF UST-D(12/2007)4/4