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(Agency Use Only) Ibis plannhh/////has been ravi mel: /)q7A1ppnve4 ❑Approved With Conditio Local Agency Signature: �i'� t/� Dare: Art Comments or Special Co ons: UST Monitoring Plan—Page 2 Instructions Complete a separate UST Monitoring Plan for each UST monitoring system at the facility. This form most 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.) 490-54a MONITORING OF THE UNDER DISPENSER CONTAINMENT-Indicate the method used for UDC monitoring 490.54b.SPECITY-If 99"Other"is checked,describe other method uced If Vl-i-1,VI-1-2 or VI-i-3 or V1-1-99 is checked,complete 49455 to 490-64b. 490-55. PANEL MANUFACTURER-Enter the name of the manufacturer of the monitoring system control panel(console). If them is ne mount}anti(e.g.,only an electrical relay box is installed)leave this space blank. 49456. MODEL a- Enter itis 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 49457. LEAK SENSOR MANUFACTURER-Emu the name of the manufacturer of the sensot(s). 490.58. MODEL g(S)-Enter the model number of the seawr(s)installed If additional space is nsded.use Section X. 49459. DETECTION OF A LEAK INTO THE UDC TRIGGERS AUDIBLE AND VISUAL ALARMS. Indicate Yes or No 490.60. UDC LEAK ALARM TRIGGERS PUMP SBUfDOWN-Indicate Yes or No 490-61. FAILUREWISCONNECTTON OF UDC MONITORING SYSTEM TRIGGERS AUTOMATIC PUMP SHUTDOWN-Indicate Yes or No 490-62. UDC MONITORING STOPS THE FLOW OF PRODUCT AT THE DISPENSER-Indicate Yes or No. 49063. UDC CONSTRUCTION- Indicate if the commotion of the UDC is single-walled,or double-walled- 490-64. ouble-walled490-64e.DOUBLE-WALLED ngTFASTMAL SPACE MONITORING- Indieam what is used to monitor me imerarmal state. 490-64b.LEAK WITHIN THE SECONDARY CONTAIMENT OF UDC TRIGGERS AUDIBLE AND VISUAL ALARMS-Indicate Yes or No 490.65. VII-I ELD TESTING-Cheek the box ifyou have been notified by the State Water Resounxs Contort Board(SWRCB)than the USf(s)covered by this plan isrme subject to Enhanced Leak Detection Rryumarents(i.c,UST has any single-wall component and is located withdn 1.000 f ct of a public drinking svaer well). 49466. TESTING OF SECONDARY CONTAINMENT COMPONENTS EVERY 36 MONTHS-Check the box if you have secondary containment elect requires testing. 49467. SPILL BUCKET TESTING-Check the box if you have spill buckets. 4911aa-h.VIII RECORDKEEPING-indicate which monitoring and equipment mointenmee records are maintained for this facility. 490-69a IX TRAINING STATEMENT-Check the box to verify that the statement is true. REFERENCE DOCUMENTS MAINTAINED AT FACILITY-Check the appropriate boxes to describe reference documents maintained at the facility. Now that the cast two items;on the list must be kept at the family. 490-696. MONITORING PLAN:Indicate that this plan is kept as a reference document. 490.69Q OPERATING MANUALS FOR ELECTRONIC EQUIPMENT Indicate that this plan is kept as a reference documenL 490-69(. CAUSTREGULATIONS-Indira dwtlmiskgAwanfe o docuaent 490-69e. CAUSTI.AW-Itdicalethatthis is kept asanfermcedocumern 49069f.STATE WATER RESOURCES CONTROL BOARD(SWRCB)PUBLICATION- "HANDBOOK FOR TANK OWNERS-MANUAL AND STATISTICAL INVENTORY RECONCILIATION-indicate that this is kept as a refererax document. 49469g.SWRCB PUBLICATION:"UNDERSTANDING AUTOMATIC TANK GAUGING SYSTEMS":Indicate that this is kept 0 a reference document. 490-69h.OTHER-Indicate mm other reference,docwnems are kept 490-691. SPECIFY-if-OTHER"is checked.enter a brief description of the other doctment(al maintained at the facflty.Ifadditional space is needed,see Section X. 49470. DESIGNATED OPERATOR TRAINING-Check this box to verify that this statement is true. 490.71. COMMENTS/ADDITIONALINFORMATION-Makeadditianalrommemsoryoumayatachandid nfymcnumbcrofadditiondpagmofinfometiontod hhe any additional UST system mordloring-Mated information(erg.,additional infomation required by your local agency) Anach my monitoring logs that you will be ming far the monitoring ofyour tank system 49472. NAME-Enter the name of the person who routinely conducts the monitoring and equipment maintenance under this plan 49473. TITLE- Enter the title of the person. 49474 NAME-Enter the name of the second person,if applicable,who routinely conducts the monitoring and egwpment maintenance under this plan. 49475. TITLE- Emerthe tide of the second person OWNER/OPERATOR SIGNATURE-The tank ovmedoperator,facility owaerfopemtor,or an authorized representative of the owner shall sign in the space provided- This rovidedThis signature certifies that the signer believes that all information subm(rted is true,accurate,and complete,and that the training program specified in Section IX has been implemented. 49476. REPRESENTING-Check the appropriate box to indicate whether the signer is the UST owcer/operator,the UST facility outer/operator,or an authorized representative of the owner. 490-T/. DATE-Enter the date the plan was signed. 49478. APPLICANT NAME-Print or type the name of the person signing the plan. 490.79. APPLICANT TITLE-Enter the tide of the person signing the plan. UPCF UST-D(12/2007)414