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(Agenry Use Only) This plan has been reviewed and: IC{Approved ❑Approved With Conditions Local Agency Signature �l/Yk_.fA.A.4� .✓-?1/4� Date, Comments or Special Coadmons: UST Monitoring Plan—Page 2 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 that your local agency may require you to obtain approval prior to installing or modifying monitoring equipment. (Note: Numbering of these instructions follows the data element numbers on the form.) 490-54e.MONITORING OF THE UNDER DISPENSER CONTAINMENT-Indicate the method used for UDC monitoring. 490-54b.SPECIFY-IF99"Other"is checked,describe other method used. If VI-I-I,V1-1-2 or VI-1-3 or VI-1-99 is checked,complete 490-55 to 49064b. 490-55. PANEL MANUFACTURER—Enter the name of the manufacturer of the monitoring systent control panel(console). If them is no control panel(e.g.,only an electrical relay box is installed)leave this space blank 490-56. MODEL g- Enter the model number for the monitoring system control panel(console).If there is no control panel(e.g,only an electrical relay box is installed)leave this space blank. 490-57. LEAK SENSOR MANUFACTURER—Enter the name of the manufacturer of the scruce(s). 490.58. MODEL e(S)—Enter the model number of the assistants)installed.If additional space is needed,use Section X. 490.59. DETECTION OF A LEAK INTO THE UDCTRIGGERS AUDIBLE AND VISUAL ALARMS. Indicate Ycsor No 490-60. UDC LEAK ALARM TRIGGERS PUMP SHUTDOWN-Indicate Yes or No 49061. FAILURF%DISCONNECTION OF UDC MONITORING SYSTEM TRIGGERS AUTOMATIC PUMP SHUTDOWN-Indicate Yes"No 49062. UDC MONITORING STOPS THE FLOW OF PRODUCT AT THE DISPENSER-Indicate Yes or No. 490-63. UDC CONSTRUCTION- Indicate if the construction of the UDC is single-walled,or double-walled. 490.64a DOUBLE-WALLED INTERSTITIAL SPACE MONITORING- Indicate what is used to monitor the interstitial space. 490-64b.LEAK WITHIN THE SECONDARY CONTAIMENT OF UDC TRIGGERS AUDIBLE AND VISUAL ALARMS-Indicate Yes or No 49065. VB-I E•I.D TESTING-Check the box ifyou have been notified by the State Water Resources Control Board(SWRCB)that the UST(s)covered by this plan is/am subject to Enhanced Leak Detection Requirements(i.e.,UST has any single-wall component and Is located within 1,000 feet of public drinking water well). 49066. TESTING OF SECONDARY CONTAINMFNT COMPONENTS EVERY 36 MONTHS-Check the box ifyou have secondary containment that requires testing. 490-67. SPILL BUCKET TESTING-Check the box if you have spill buckets 490-68a-h.VIII RECORDKEEPMG-Indicate wbich monitoring and equipment maintenance records are maintained for Otis facility. 490.69a IX TRAINING STATEMENT-Check the box to verify that the statement is true. REFERENCE DOCUMENTS MAINTAINED ATFACILITY—Check the appropriateboxesto describe referencedocuments maintained in the facility. Notothatthe first mo items on the list must be kept at the facility-. 49069b. 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. i 490-69d. CA UST REGULATIONS-Indicate that this is kept as a reference document. 490-69e. CA UST LAW-Indicate that this is kept as a reference document. 490-69f.STATE WATER RESOURCES CONTROL BOARD(SWRCB)PUBLICATION- "HANDBOOK FOR TANK OWNERS-MANUAL AND STATISTICAL INVENTORY RECONCILIATION-Indicate that lids is kept as a reference document. 490698 S WRCB PUBLICATION:"UNDERSTANDING AUTOMATIC TANK GAUGING SYSTEMS":Indicate that this is kept as a reference document. 49069h.OTHER-Indicate that other reference damments are kept. 490-69i. SPECIFY-if"OTHER"is checked,enter a briefdescription of the other daument(s)maintained at the facility.If additional space is needed,see Section X. 490.70. DESIGNATED OPERATOR TRAINING-Checkthis box to verify that this statement is true. 490-71. COMMENTS/ADDITIONAL INFORMATION—Make additional comments or you may attach and identify the number of additional pages of information to describe any additional UST system monitoring-related information(e.$,additional information required by your local agency). Attach any monitoring logs that you will be using for the monitoring of your Isnk system. 490-72. NAME—Enter the mine of the person who routinely conducts the monitoring and equipment maintenance under this plan. 490-73. TITLE- Enter the title of the person. 490-74. NAME—Enter the name of the amend person,if applicable,who mutialy conducts the monitoring and equipment maintenance under this plan. i 490-75. TITLE- Enter the title ofthe second person. OWNEWOPERATOR SIGNATURE—The tank mvmedopemmr,facility owner/operetar,or an authorized representative ofate owner shall sign in the space provided. This signature certifies that the signer believes that all information submitted is true,accurate,and complete,mid that the training program specified in Section IX has been implemented. 490-76. REPRESENTING—Check the appropriate box to indicate whether the signer is the UST owner/operator,the UST facility osvner/operator,or an authorized representative of the owner. 490-77. DATE—Enter the date 9ie plan was signed. 490-78. APPLICANT NAME—Print or type the rine of the person signing the plan. 490-79. APPLICANT TITLE—Enter the tide of the person signing the plan. UPCF(IST-D(12200.7)414