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(dgency Use 0*) This plan has been roti A Iwd A ed ©Approved With
<br /> Local Ag=cy Signature: Date:
<br /> Cora"or Special coaditsim
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<br /> UST Monitoring Plan—Page 2 Instructions
<br /> Corttplete q soptmate UST Monitoring]Plan for each US']' monitoring system at the facility. This!form ntnsl be submitted with your initial UST
<br /> Operating Permit Application and within 30 days of changes in the information itcontains. Please note that your local agency may require you to
<br /> ohbtain approval V.V&to installing or modifying monitoring equipment. (Note: Numbering of these instructions follows the data clement numbm-s on
<br /> 490-54a.MONITOR Mr,OF THL UNDER DISPENSER CONTAINMENT-Indicate the method"
<br /> sed 490-54b.SPECIFY-If 99`Other"is chmkod,describe other method ustxt for UDC moaitonN,
<br /> If VIA-1,V1-1.2 or VI-1.3 or VI-I-99 is chocked,complete 490-55 to 490-64b.
<br /> 490-55. PANEL MANUFACTURER—Enter the name,Of the manufacturer of the monitorine system enntrnl panel(ce>tiaalei). If there iy no control
<br /> nctay L.,e iu i'QUiled)leave this space bland I,nttci(r.g.,only an cltxtrlcal
<br /> 490-56. MODEL#- Enter the model number for the monitoring sygtem control panel(console)
<br /> this .if there is no control r tel(c-g-,only an electrical relay box is installed)leave
<br /> space blank,
<br /> 490-57. LEAK SENSOR MANUFACTURER—Enter the name of the manufacturer of the smsor(s),
<br /> 490-58. MODEL 9(S)—Enter the model number of the sensor(s)irtstailcd.If additional space is needed,use Section X.
<br /> 49t)59. DETECTION OF A LEAK INTO THE UDC TRIGGERS AUDIBLE AND VISUAL ALAP S, Indicate Ye;or No
<br /> 490-4f1 UDC LEAK ALARM TRIGGLRS PUMP SHUTDOWN- Indicate Yes or No
<br /> 490-61. FAILURE/DISCONNECTION OF UDC MONITORING SYSTEM TRIGGERS AUTOMATIC PUMP SHU`7 WN-Indicate Yes or No
<br /> 490-62_ UDC MONITORING STOPS'THE FLOW OF PRODUCT AT THE DISPENSER-Indicate Yes or No.
<br /> 490-63, UDC CONSTRUCTION- Indicate If the consttuttion Of the UDC is�.in ic.wallt?4 or double wolkd_
<br /> 490-a4a.DOUBLL-WALLED INTERST'ITLALL SPACE MONITORING- Indicate what is used to monitor the imerstitittl�We.
<br /> 490-64b.LEAK WTMIN THE SECONDARY CONTAIMENT OF UDC TRIGGERS AUDIBLE AND VISUAL ALARM
<br /> 490-65, VII-1 ELD TESTING-Check the box if you have been notified by the State Water Resources Control Board(SVI(RCB)dihat the UST s1 covered by this plan i./ttro
<br /> subjtxt to Fnhnnr..xi Leak Detection Ruquiromeaua(i.c.,UST Lon tory single-wall component and is located with' 1,000 rest of a public drinking water well).
<br /> 490-66. TESTING OF SECONDARY CONTAINMENT COMPONENTS EVERY 36 MONTHS-Chock the box if you),avc secondary containment that requires testing
<br /> 490-67, SPILL BUCKET TESTING-Chock the box if you have spill buckets,
<br /> 490.68a-h,Vill RECORDKEEPING-Indicate which monitoring and equipment Ina intcnanee n,_is e„e mainrainttd tar a facility,
<br /> 490-69a IX TRAINtNCj STATEMENT-Check the box to verify that the statement is true.
<br /> REFERENCE DOCUMENTS MAINTAINED AT FACILITY—Check the appropriate boxes to describe refercnire documents maintained at the facility. Note that the
<br /> first two ite nis on the list rqW be kept at the facility.
<br /> 490.69b. MONTfORING PLAN-Indicate that rhis Plan is kept a.a refamnoe dace--t_
<br /> 490.69c. OPERATING MANUALS FOR ELECTRONIC EQUIPMENT:Indicate that this plan is kept as a reference doeeat.
<br /> 490-69d. CA UST REGULATIONS-Indicate that this is kept as a reference document, �"
<br /> 490-69c. CA UST LAW-Indicate that this is kept as a reference document „„,
<br /> ao0.69f!STATE WATER RESOURCES CONTROL BOARD(SwKC13)PUBLICATION- "HANDBOOK FOR TANK OWNERS-MANUAL AND
<br /> STATISTICAL INVENTORY RECONCILIATION-Indicate that this is kept as a refe rmcc document,
<br /> 490-69g.S WRCB PUBLICATION:"UNDERSTANDING AUTOMATIC TANK GAUGING SYSTEMS Indicate that this is kept as a refercnce document.
<br /> 490-69h.OTHER-Indicate that other reference de nitnents are kepe.
<br /> 490-69i, SPECIFY-if'OTHER"is checked,enter a brief description of the other doeiunent(s)maintained ut the facility.If Idditional space is needed,see Section X
<br /> 490-70. DESIGNATED OFERA'fOR TRAINING-Check this box to verify that this statement is trot,
<br /> 490-71_ COMMENTS/ADDITIONAL INFORMATION—Make additional comments or you nlay attac4 and identify the number of ariditioml pages of inrbr>sution to dcxribc
<br /> any additional UST oyytcm monitoriuq;-tclaual intbrmatlon('e.g„additional imbraration required by your local uge4cy). Attach any monitoring logs that you will be using
<br /> for the monitoring of your tank systems.
<br /> 490-72, NAME—Enter the name of the person who routinely conducts the monitoring and equipment maintenance under this plan.
<br /> 490-73, TITLE- Enter the title of the person.
<br /> 490-74, NAME—Enter the flame of the second person,if applicable,who routinely conducts the monitoring and cquipmeut Imainlcnancc under this plan_
<br /> 490-75. TITLE- Enter the title of the second ptseon,
<br /> OWNER/OPERATOR SIGNATURE—The tank owner/opq�ator,facility owner/operator,or an authorized represen4ative of the:owner sltxll cjgp in the.pact provided,
<br /> This silrrumvr cenife.that the iffier be l;eties that all iulu„tuAion autxnl[ied 1N true,accurate,and eompleie and t}ta{the training Prngratn specified in Section IX has
<br /> been implemented
<br /> 490-76. REPRESENTING--Chmk the appropriate box to indicate whether the signer is the UST owner/operator,the UST�'Wility owner/operator,or an
<br /> authorized representative of the owner.
<br /> 490.77. DATE—Enter the date the plan was sighed.
<br /> 490-78. APPLICANT NAME—Print or Iypo the name of the person signing the plan,
<br /> 490.79, APPLICANT TITLE—Enter the title of the person signing the plan
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<br /> UPC1F UST.D(12/ZO"4/4
<br /> 6©/P9 39dd 000-J SV9 3N0 V 9L9?8686aZ TO:ZO 6ee7,/80/01
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