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NEW T PETROLEM Fax Aug 13 2009 10:32am P018/022 i.a�cn,.y ver v'cty/ r rata Iu:ur atub uealt rev ono: Approved U Approved want'1W ~ i Local Agency Signature: it-VADate: Comments or Special Conditions: - I � I UST Monitoring Plan—Page z 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 ]•at your local agency may require you to obtain approvalrp for to installing or modifying monitoring equipment, (Note: Numbering of these inst;Ucti ins follows the data element numbers on the font.! 490-54a.MONITORING OF 7'IIF.UNDER DISPENSER CONTAINMENT-Indicate the method used i'or UDC monitoring. 490-54b.SPECIFY-If 99"Other'is checked,describe other mothod used. If VI-I-t,VI.1.2 or VI-1 3 or VI-1-99 is checked,complete 490-5$to 490-64b. 490-55. PANEL MANUFACTURER..Enter the name of the manufacturer of the monitoring system control panel(console). If i'i ere is no conrol panel(c,&only ar electrical relay box is installed)!cave this space blank. 490.56. MODEL v- Enter the model number for the monitoring system control panel(console).If there is no control panel(..;.,only an electrical rel ty box is installed))rave this space blank. 490-57. LEAK SENSOR MANUFACTURER-Enter the name of the manufacturcr ofthe scrsor(s). 490,:S MODEL rn S)-Enter the model number of the:ensor(s)installed.If additional space is needed,use Section X. 490-59. DETECTIO'NOF A LEAK INTO THE UDC TRiGGFRS AUDIBLE AND VISUAL ALARMS. Indicate Yes or No 490-00. UDC LEAK ALARM TRIGGERS PUMP SHL:TDOWN- Indicate Yes or Ito 490-61. FAILUR.BYDISCONNE CfION OF UDC MONITORING SYSTEM TRIGGERS AUTO\1AT1C PUMP SHUTDOWN• ndicalc Yas or No 490-02. UUC MONITORING STOPS THE FI.,OW OF PRODUCT AT THE DISPENSER-Indicate Yes or No, 490-63, UDC CONSTRUCTION- Indicate if the construction of the UDC is single-walled,otdoublc-walled, 490-64a.DOUBLE-WALLED IKTFRSTITIAL SPACE MONITORING- indicate what is used to monitorthe interstitial space. 490.64b.I.EAK WITHIN THE SECONDARY CONTALVIENT OF UDC TRIGGERS AUDI131 E AND VISUAL ALAR_NIS-In:icate Yes or No 490-`S. Vit-1 ELD TESTING-C*reck the box if you have been notified by the State Fater Resources Control Board(SWTeCB) hat the UST(s)covered by this plan is/are subject to Enhanced I,.eak Detection,Requirements(i.e.,UST has any single-wall component and is located within 1,0(0 feet of a public drinking water well). 490-00 TESTING OF SECONDARY CONTAINMENT COMFONENTS EVERY 36 MONTHS-Check the box if youhave:c:endary containment that requires testing. 490-67. SPII_I,BUCKET TCSTING-Check the box if you have spill buektxs. 490-08a-h.VIII RFC0RDKELI1rNG-indicate which monitoring;and equipment maintenance records are maintained for this rae It 490-69a IX TRArl,rNG STATE;Y4ENT-ClTeck the box to verify that the statement is true. REFERENCE DOCUMENTS MAINTAINED AT FACILITY-Check the appropriate boxes to describe reference dune mens maintained at the facility, Note that the fimt two Berns on the list nw be kept at the facility. 490-096. V ONITORING PLAN:Indicate that this plan is kept as a reference document. 490-69c. OPFMATING 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, 490-69e. CA L'ST LAW-Indicate that this is kt1pT as a reference document. 490-691'.STATE WATER RESOURCES CONTROL BOARD(SWRC13)PUBLICATION- -HANDBOOK F'OR TAMC O%VNL-RS-MANUAL AND STATISTICAL INVENTORY RECONCILIATION-Indicate that this is kept as a reference document. 490.09,.SWRCB PUBLICATION:-UNDERSTANDING AUTOMATIC TANK GAUGING SYSTEMS":lndicate that:h s is kept tt5 a reference documa r. 490,69h.OTHER-Indicate that other reference documents are kept. 490-69i. SPECIFY-117"OTHER"is checked,enter a brief description ofthe other documents)maintained at the facility.If addit cr)al space ie ngedcd,see Suction X. 490•?0. IJUSIGNATFO OPERATOR TRAINING-Check ibis box to verify that this statement is true. 49()-71. COM MENTS/ADDITIONA1.TNFOR:VIATIO'N-Make additional comments or you may attach and identify the ntmthei of addiiiona)pages oflnikirmatien to describe any additional UST syst m)monitoring-related information(e.g.,additional information required by your local agency). .attach any monitoring ioysibat you will be using for the-not+itoring oryota tank system. 490-72. NAME-inter the namu of Lne person who routinely conducts the monitoring and equipment maintenance under this pl ar. 4110,73. 'T rr.,- Enter the title ofthe person. 491;_74. NAME-Enter the name ofthe second person,if applicable,who routine)yconducts the monitoring and equipment Tnai,:;nancc under this plan. 490--S. 'I ITLF.- Enter the title ofthe second person. OWNER/OPERATOR SIGNATURE--The tank owner/operator,facility ownerroperator.or an authorized rcprks<r,tati%; afthe o%vner shall sig ri in the apace provid,{. Thio signature certifies that the signer believes that all information submitted is true,accurale,and complete,and that tbv;wining;program specified in Section IX has beer.implanented. 490-76. rtlil1RL`.ti1:N'fl\Ci--Check the appmpr ate box to indicate whether the signs;is the 11S I'ownrr/oncrator.the UST fh6l.t: 0w1te,orcr*X,,1,ar an Iluthurized 7YprGSV;;taliv.of the owner. 49(8.77. DA I'L 1 utter'the date jnr.plus was signed. 49O-7h. APPLICANT NANIF-Print or ryl)c the name of rho person signing the plan. 4,)o-79. AITLIC AN'i TITI..t:--F%;ltur tic title ori:c person signing th pian. t !'t:Ir RJ5Z-ID(1212007)4,4