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01/08/2004 08:23 20946834/1 FIFTH FLOOR PAGE 14
<br />UST Monitoring Plan - Page 1, Instlructions
<br />Complete a separate UST Monitoring Plan for each UST monitoring system at the facility. This form must be submitted with your inf:ial'. UST
<br />Operating Permit Application and within 30 days of changes in the information it contains. Plcase note that your local agency may require you to
<br />obtain approval prior to installing or modifying monitoring equipment. (Note' Numbering of these instructions follows the data element numbers on
<br />the form.)
<br />MOL TYPE OF ACTION - Check the appropriate box to indicate why this plan is being submitted.
<br />M02- PLAN TYPE -Cheek the appropriate box to indicate whether this plan covers all, or merely some, of the USTs at the facility. If tae piaci covers only
<br />some of the tanks, identify those tanks in the space provided [e.g., by using the Tank ID #(s) in item 432 of the UST Operating Permit Applimfion -
<br />Tank Form(s)),
<br />FACILITY ID NUMBER - This space is for agency use only.
<br />M03- FACILITY NAME - Enter the complete Facility Name.
<br />M04. FACILITY SITE ADDRESS -Enter the street address where the facility is located, including building number, if applicable. Post office box numbers
<br />arc not acceptable. This information must provide a moans to locate the facility geographically.
<br />M05. CITY - Enter the city or unincorporated area in which the fhcility is located.
<br />M06. MONITORING EQUIPMENT IS SERVICED - Checked the appropriate box to 5pccif7 the frequency of monitoring cquipricnt testing/ccrtification.
<br />M07. SPECIFY - if item 11-99 is checked, enter the frequency of monitoring equipment testing/certification.
<br />M10. TANK MONITORING METHOD(S) - Check the appropriate box(es) in Section IV to identify all required methods used for monitoring UST(s)
<br />covered by this plan.
<br />M 11. SECONDARY CONTAINMENT IS - Check the appropriate box to describe the environment inside tank secondary containment.
<br />M12. PANEL MANUFACTURER - If item IV -1 is checked, enter the name of the manufacturer of the monitoring system control panel (consol e).
<br />Mia. MODEL # - If item IV -1 is checked, enter the model number for the monitoring system control panel.
<br />M14. LEAK SENSOR MANUFACTURER - If item IV -I is checked, atter the name of the manufacturer of the sensor(s). If additional space is needed, use
<br />Section 1X.
<br />M1.5, MODEL #(S) - If item IV -1 is checked, enter the model number for each type of sensor installed. If additional space is needed, use Section EC
<br />M16, PANEL MANUFACTURER - If item IV -2 is checked, enter the name of the manufacturer of the monitoring system control panel (console:).
<br />MIT MODEL # - if item IV -2 is checked, enter the model number for the monitoring system control panel.
<br />MIS. IN -TANK PROSE MANUFACTURER - if item IV -2 is checked, enter the name of -the manufacturer of the probe(s).
<br />M19. MODEL #(S) - If item IV -2 is checked, cntcg the model number for each type of in -tank probe installed. If additional space is'needed, use Seetior: IX.
<br />M20. LEAK TEST FREQUENCY- If item IV -2 is checked, check the appropriate box to describe the in -tank leak test frequency.
<br />M21. SPECIFY - If item M20 -e is checked, enter the frequency of programmed leak tests -
<br />M22. PROGRAMMED TESTS - If item IV -2 is checked, check the appropriate box to describe the tests programmed into the ATG systera.
<br />M23. SPECIFY - If item M22 -c is checked, enter the frequency of in -tank Icak testing.
<br />M24. INVENTORY RECONCILIATION - If item IV -3 is checked, check the appropriate box to describe the type of inventory reconciliation performed
<br />(i.e., Manual or Statistical).
<br />M25, TESTING PERIOD - If item IV -4 is checked, check the appropriate box to describe the MTG testing period.
<br />M26. TEST FREQUENCY - If item IV -5 is checked, check the appropriate box to describe the frequency of tank integrity testing
<br />M27. SPECIFY - If item IV -5-c is checked, enter the frequency of tank integrity testing.
<br />M28. SPECIFY - If item IV -99 is checked, enter a brief description of the other tank monitoring method(g) used (e.g., vadose zone mon toring par 2.3 "_'CR
<br />§2647, groundwater monitoring per 23 CCR §2648). Include the monitoring frcqumey (c -g., Continuous, Weekly). If additional saaee is needed, use
<br />Section LY.
<br />M30. PIPE MONITORING ME7i3OD(S) - Check the appropriate box(cs) in Scotian V to identify all requited methods used for monitoring piping in the
<br />UST systcm(s) covered by this plan.
<br />M31. SECONDARY CONTAINMENT IS - Check the appropriate box to describe the environment inside piping secondary containment.
<br />M32. PANEL MANUFACTURER - if item V-1 is checked, enter the name of the manufacturer of the monitoring system control panel (console).
<br />M33. MODEL # - If item V-1 is checked, enter the model number for the monitoring system control panel.
<br />M34. LEAK SENSOR MANUFACTURER - If item V-1 is checked, enter the name of the manufacturer of the sensor(s).
<br />M35. MODEL #(S) - if item V-1 is checked, enter the model number for each type of sensor installed. If additional space is needed, use Section IX.
<br />M36, WILL PIPING LEAK ALARM TRIGGER PUMP SHUTDOWN? - If item V-1 is checked, check Yes or No.
<br />M37, WILL FAILUR)B/DISCONNECTION OF MONITORING SYSTEM TRIGGER SHUTDOWN? -if item V-1 is checked, check Yes or No.
<br />M38. MLLD MANUFACTURER(S) - If item V-2 is checked, enter due name(s) of the maaufacturer(s) of the mechanical line leak dctcctor(s). if additional
<br />space is needed, use Section IX.
<br />M39. MODEL #(s) - If item V-2 is checked, enter the model number for each type of mechanical line leak detector installed- if additional space is ncx:ded,
<br />use Section IX.
<br />M40. ELLD MANUFACTURER - If item V-3 is checked, enter the name of the manufacturer of the electronic line leak detector(s).
<br />M41. MODEL #(S) - if item V-3 is chocked, enter the model number for each type of electronic line leak detector installed. if additional space is needed, use
<br />Section IX.
<br />M42. PROGRAMMED LINE INTEGRITY TESTS - If item V-3 is checked, check the appropriate box to describe the type of tests prograsruned veto the
<br />monitoring system,
<br />M43- WILL ELLD DETECTION OF A PIPING LEAK ALARM TRIGGER PUMP SffUTAOWN? - If item V-3 is checked, check Yes or No.
<br />M44. WILL ELLD FAILUREMISCONNECTION TRIGGER PUMP SHUTDOWN? - if item V,1 is chocked, check Yes or No.
<br />M45. TEST FREQUENCY - if item V-4 is checked, check the appropriate box to describe the frequency of pipe integrity testing.
<br />M46. SPECIFY r- If item V -4-c is checked, enter the frequency of pipe integrity testing.
<br />M47. VISUAL MONITORING DONE - If item V-5 is chocked, check the appropriate box to describe the frequency of visual monitoring.
<br />M48. SPECIFY - If item V-99 is checked, enter a brief description of the other line monitoring method(s) used. If additional space is r..eeded, use &-ction
<br />I.X. Be sure to clearly describe monitoring mcthod(s) and frequency.
<br />This monitoring plan must include a Site Plan showing the general tank and piping layouts and the locations where monitoring is performed (i.c.. )ocatinn of
<br />each sensor, line leak detector, monitoring system control panel, etc.). If you already have a diagram (e.g,, current UST Monitoring Site Plan };-om a
<br />Monitoring System Certification form, Hazardous Materials Business Plan map, etc.) which shows all required information, include it with this plan.
<br />SJCEHD-d (07103) - 214 0712:3103
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