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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 forth.) M50. DISPENSER MONITORING METHOD(S)—Check the appropriate box(es)in Section IV to identify all required methods used for monitoring the steals)beneath the dispenser(s). If no dispensers are installed(e.g.,USTs supplying standby generators),check item VI-5. M51. PANEL MANUFACTURER—If item VI-1 is checked-enter the time of the manufacturer of 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. M52. MODEL#—If item VI-1 is checked,enter the model number for the monitoring system control panel.If there is no control panel(e.g..only an electrical relay box is installed)leave this space blank. M53. LEAK SENSOR MANUFACTURER—If item VI-I is checked,enter the time of the manufacturer of the sensor(s). M54. MODEL#(S)—If item VI-1 is checked enter the model number for each type of sensor installed.If additional space is needed,use Section IX. M55. WILL DETECTION OF A LEAK INTO UDC TRIGGER AUDIBLE AND VISUAL ALARMS?—If item VI-1 is checked,check Yes or No. M56. WILL A UDC LEAK ALARM TRIGGER PUMP SHUTDOWN?—If item VI-I is checked,check Yes or No. M57. WILL FAILURE/DISCONNECTION OF UDC MONITORING TRIGGER SHUTDOWN?—If item VI-1 is checked,check Yes or No. M58. ASSEMBLY MANUFACTURER—If item VI-2 is checked,enter the time of the manufacturer of the mechanical leak detection assembly. M59. MODEL#(S)—If item VI-2 is checked,enter the model number for each type of mechanical leak detection assembly installed. If additional space is needed,use Section IX. M60. VISUAL MONITORING DONE —If item VI-3 is checked,check the appropriate box to describe the frequency of visual monitoring. M61. SPECIFY—If item VI-99 is checked,enter a brief description of the other method(s)used to monitor the UDC. If additional space is needed, use Section IX. M70. ENHANCED LEAK DETECTION —Check the box if you have been notified by the State Water Resources Control Board(SWRCB)that the UST(s)covered by this plan is/are subject to Enhanced Leak Detection Requirements(i.e.,UST has any single-wall component and is located within 1,000 feet of a public drinking water well). M80. REFERENCE DOCUMENTS MAINTAINED AT FACILITY—Check the appropriate boxes to describe reference documents maintained at the facility. Note that items 1,2,and 3 must be kept at the facility. M81. SPECIFY—If item VIII-99 is checked, enter a brief description of the other document(s)maintained at the facility. If additional space is needed,use Section IX. M85. COMMENTS/ADDITIONAL INFORMATION — You may use this section to describe any additional UST system monitoring-related information(e.g.,additional information required by your local agency). If using Section IX as additional space for items required elsewhere in this plan,reference the item number(e.g.,"Item M54-Model 2468 and 3579 Leak Sensors"). OWNER/OPERATOR SIGNATURE—The owner/operator shall sign in the space provided. This signature certifies that the signer believes that all information submitted is true,accurate,and complete,and that the training program specified in Section VIII has been implemented.. M90. REPRESENTING—Check the appropriate box to indicate whether the signer is representing the UST owner or UST operator. M91. DATE—Enter the date the plan was signed. M92. OWNER/OPERATOR NAME—Print or type the time of the person signing the plan. M93. OWNER/OPERATOR TITLE—Enter the title of the person signing the plan. SJCEHD-d(07/03)-4/4 07/23/03