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10/03/2007 09:42 #0050 P.012 /021 (Ag-W Use Only) This plan has beast; 'e end [ Approaed With Colmditi Local Agency Stpm,= ANK— : Commetas or Spatial Conditioffim: UST Monitoring Pian—Page z Instructions Complete a separate UST Monitoring Plan for each UST monitoring system at the facility. This form ffiust be submitted with yomr initial IJST Qpelafing Permit Application and within 30 days of changes in tho inforizution it contains. P1=c note shat your local�gcncy may require you to obtain approval Mor to installing or modifying monitoring equipment- (Note: Numbering of these inst—bons follows the data clement nemrbem on the foam.) 490-540-MONTI ORING OF THP UNDER DISPENSER CONTAINMENT.Indicate the method used for UDC moartorm& 490.54b.SPECIFY-If 99"Odea"is decked,describe odd method used, If VI-t-1,vI-I-2 or VI-I-3 or VI-1-99 is cheekvd,complete 490-55 to 490-64b. 490-55. PANEL MANUFACTURER-Eater the name of the manufacnucr of the monitodng$ystrm oomol Fuld(joie). If there ig uo control panni(e•g.,okty alt deccical relay Ica is installod)leave this space blank 490.56. MODEL€- F,ata the morcel number for the monitoring system control pane!(eowulc�If that is no control pane!(e.g.drily an elaxirical relay ix�x is installel)leave this space blank. 4590.57. LEAK SENSOR MANUFACTURER-Enter the new of the nrentrfacturer of the sensor(s). 490-58. MODEL#(S)-Enter the model nu mbw of the sensor(s)installed.If additional space is nee"use Section X. 490-59. DUTECTION OF A LFAK INTO THE UDC TRIGGERS AUDIBLE AND VISUAL ALARMS. Indicate Ycs or No 490-60. UDC LEAK ALARM TRIGGERS PUMP SHUTDOWN- Indicate Yes or No 490.61. FAlLURODISCONNECILON OF:IDC,MONITORING SYSTEM TRIGGERS AUTOMATIC PUMP SHUTDOWN-Indicate Yes or No 4q"2. UDC MONMORING STOPS T11E FLOW OF PRODUCT AT THE DISPENSER-Indicate Yes or No. 490.63. UDC CONSTRUCTION. Indicate if the consnuefimofthe UDC is single-walled,or double-walled. 490.64a,DOUBLE-WALLF.p INTERSTTTIAL SPACE MONITORING- Indicate what is used to monitor the inturstitial space, 490.64b.LEAK WITHIN THE SECONDARY CONTAU&NT OF UDC TRIGGERS AUDIBLE AND VISUAL ALARMS-Indicate Yea or No 490.65. V11-1ULD TESTING-Chepk the box ifyou haw been notified by the,State Water Rosotaces Control'Board(SWRCB)*w the UST(s)covered by this plan is/= subjw to Enhanced Leak Damon Rcalrcrements(i.ea.UST las any shnglcwall winponew and is located within 1.000 feet Of a public drinking Water wrdl), 490.66, BESTIPK'a OF SECONDARY CONTAINMENT COMPONENTS EVERY 36 MONTHS-Chock the box ifyou have secondary contrunment 1Iat requires testing, 490.67. SPILL BUCKET'MSTING-Check the box ifyou have spill lac 44048a-k VIII RECORDKEEPING-Indicate which mouito Ing wul oquipment wairacmazicc records are maintained for this facility. 490.69E IX TRAINING STATEMENT-Cheek the box to verify that the smiemgnt is true. R.EFFR_NCE DOCUMENT'S MAINIATNZ:D AT F•ACI.TTY-Checktlx appmMate boxes to maintained at the facility. tie&K tbe first two items on the list must be kept a the facility. 440.69b. MONITORING PLAN:lndicatc that this plan is kqn as a rt fennel:document. 490.690. OPERATING MANUALS FOR ELECTRONIC EQUIPMENT:Indicate that this plan is kept as a refcrer"doeutnaat. 4904X CA UST REGULATIONS-Indicate that this is Kept as a reference docrancirt 490.69e. CA UST LAW-Indicate that this is kept as a mference document, 490.690 STATE WATER RESOURCES CONTROL BOARD(SWRCB)PUBLICATION- "HANDBOOK FOR TANK OWNERS-MANUAL AND STATISTICAL INVENTORY RECONCILIATION-Indicate that this is kept as a refurenov d+ct+menr 490.698,SWRCB.PUBLICATION;"UNDERSTANDING AUTOMATIC TANK GAUGING SYSTEMS" Indicate that this is kept as a refers doctuncnt 490.69h.OTHER-Indicate that other rckience docs rn=are kept 440.691 SPECIFY-it"OTIIER is checked,enter a laivfdtscription of the odwdomment(s)trutintainedattlic facility.Ifadditional spaceis needed.sm Season X. 490-70. DESIGNATED OPERATOR TRA 1NtNG-Check this box to verify that this staternma is true. 490-71. COMMENTS/ADDITIONAL INFORMATION-Make additional comments or you may aitaoh and identify the number of additional pages of ialkatation to describe any additional UST system mortitorizWTelated intbrmatim(rag_additional information required by your foal obwcy). Attach any montiwriug logs that you wall be using for the rnordtoring of yourtank systesrr. 490-72, NAME-Eater the name of the paw who routinely conducts the monitoring and equipment maintatunce under this ply 490-73. TITLE-Ener she tide of tbo pecion. 490-74. NAME-Eater the n nc of the second person,if applicable,who rmaincly conducts the monitoring and equipment ma!ntenance underthis plan. 490-75, T=-Enter the title ofthe seeped person. OWNER/OPERATOR SIGNATURE-The tank ownedoperator,facility ownceoperator,or an Authorized representative of the owwr snail sign in the space provided. This signarm certifies that the signer believes that all information Submitted is trete,scocuati-and complete,and that the tmimW program specified in Section IX has been implemertud. 490-76. REPRESENTING-Check the appropriate box to indica:`whether the signer is the UST owner/operator,the UST facility ownes/operator,or an authori=d represcutame of the owner. 490-77. DATE-Enter the date the plan was signed. 490-78. APPLICANT NAME-print or type the name of due person sqpuns the plam 490-79. APPLlCANT'rrrLE-Enter the title of thre person signing the plan. UPCF UST-D(12/207)4/4