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(Agency Use Oml3) This plan has been reviewed and: P` Approved ❑ Approved With Conditions Local Agency Signal" ; ) /yAz Comments or Special Conditions: UST Monitoring Plan — Page 2 instructions Complete a separate UST Monitoring Plan for each USi' monitoring system at the facility. This form must be submitted with your initial UST Operating I'errit Application and Within 30 days of changes in the infonnation it contains. Please note that your local agency may require you to obtain approval prix; to installing or modifying monitoring equipment. (Note- Numbering of these instntctions follows the data element numbers on the fore.) 490-541. MONITORING OF THE UNDER DiSPENSER CONTAINMENT- Indicate the method used for UDC nonilorimg 490-54b. SPECIFY -If 99 "Olhct" is checked, describe other method used. If VI -I -I, Vi -1-2 or V1.1.3 or VI -t-99 is checked, complete 490-55 to 490-64b. 490.55. PANEL MANUFACTURER -Enter the panne of the mamsfiennrer of the monitoring system control panel (cuASOIe) Ifthere is no control panel (t.g., only an electrical relay lox is installed) leave this space blank. 49056. MODEI. N - Enter the model number for tilt monitoring system control Panel (console) If there is no control panel (e.g., only au electrical relay box is installed) leave this space blank. 490-57, LEAK SENSOR MANUFACTURER - Enter the name of the manufacturer of the sensor(s). 490-53. MODEL H(S) - Enter the model number of the sensor(s) installed. If additional space is needed, use Section X_ 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 - Indicate Yes or No 490-61. FAILURE/DiSCONNECTION OF UDC MONITORING SYSTEM TRIGGERS AUTONIATIC PUNIP SHUTDOWN - Indicate Yes or No 490.62. UDC MONITORING STOPS Ti IF FLOW OF PRODUCT AT THE DISPENSER - indicate Yes or No. 490.63, UDC: CONSTRUCTION. Indicate if the construction of (lie UDC is single -walled, or double -tial led - 490 -64a. DOUBLF-WALI-F.D INr1:RSTITIAL SPACE MONITORING - indicate what is used to monitor (lie imersfitial space. 490-64b. LEAK WITHIN THE SECONDARY CONI'AiMF.NT OF UDC TRIGGERS AUDIBLE AND VISUAL ALARMS - Indicate Yes or No -190-65 VI( -1 Fi.D TESTING - Check the box ifyuu have been notified by the State Water Resources Control Board (SWRCB) that the UST(s) covered by this plan israre 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 wen). 490-66. TESTING OF SECONDARY CONI'AiNMENT COMPONENTS EVERY 36 MONTHS -Check the box ifyuu lm,c secondary containment that requl:eS testifrg. 490.67. SPILL BUCKET TESTING - Check the box if you have spill buckets. 490.68a -h. Vill RECORDKEEPING -Indicate which monitoring and equipment maintenance records are maintained for this facility. 490.69a IXTRAIN STATEN4 -NT - Check the box to verify that the statement is tmz REFERENCE DOCUMENI'S MAINI'AINED AT FACILITY - Check the appropriate boxes to describe reference documents maintained at the facility. Note that the first two items on 11c list m 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 plan is kept as a reference document - 490 -69d CA UST REGULATIONS - Indicate that this is kept as a reference document. 490.69c. CA UST LAW - Indicate that this is kept as a rererence document. 490.69f. STATE WATER RESOURCES CONTROL BOARD (SWRCB) PUBLICATION - "HANDBOOK FOR TANK OWNERS - MANUAI. AND STATISTICAL INVENTORY RECONCILIATION - indicate that this is kept as a reference document 490-69g SWRCB PUBLICATION: "UNDERSTANDING AUI'OMAi IC TANK GAUGING SYSTEMS" ln&cale that this is kept as a reference docurnent. 490-691 OTHER - Indicate that other reference documents are kept. 490.69i. SPF.CIFYdf"Gr11ER" is checked, enters briefdescription of tlfeother docwnent(s)maintained at flit facility If additional space is needed, see Section X. 490-70. DESIGNATED OPERA'I-OR'TRAINING -Check this box to verify that this statement is tmc. 490-71, COMMF.NI'S!ADDITtONAL INFORMATION - N4ake additional comments or you may attach and iden(ifi• dee number of additional pages of infonnation to describe any additional UST systun monitoring -related infornialion (e.g., additional infonnation required by your local agency) Altach any monitoring logs that you will be using for the monitoring of you tank system. 490-72. NAME - Enter the name of (hc person who routinely conducts the monitoring and equipment maintenance under this plan. 490-73. TITLE -linter the title of the person. 490-74. NAME - Enter the name of the second person, if applicable. who routinely conducts the monitoring and equipment maintenance under this plan. 490.75 TITLE - linter the title of the second person- OWNER/OPERATOR SIGNATURE -'The tank ownedoperator, facility oicrier/operator, or an authorized representative of the owner shall sign in the space provided This signature ceniffes that the signer believes that all infonnation submitted is tae, accurate, and complete, and that the training program specified in Section iX has bear implemented. 490.76 REPRIiSEN1'ING -- Check the appropriate box to indicate whether the signer is the UST owner/operator, the UST facility omier/operalor, or an authorized represcutative 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" 1*1 ME , Enter the title of the person signing the plan. UPCF US -1'-1) (12/2007) 4/4