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Aft mr (Agency Use Only) This plan hireviewed and: /ol Approved ❑Approved With 7Conditions Local Agency Sigmatrue: --yam— Comments or Special Conditions: 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 injor 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.SPECIFY-If 99"Other'is checked,describe other method used. If VI-1-1,VI-1-2 m VI-1-3 or VI-1-99 is checked,complete 490-55 to 490-64b. 490-55. PANEL MANUFACTURER-Enter the time of the ma udammer 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. 490.56. MODEL#- Enter the model number for the monitoring system control panel(console).If there is no council panel(e.g.,only an electrical relay box is installed)leave this spew blank. 490-57. LEAK SENSOR MANUFACTURER-Enter the name of the manufacturer of the sensor(s). 490-58. MODEL#(S)-Enter the model number of the sensor(s)installed.If additional space is needed,use Section X. 490-59. DETECTION OF A LEAK INTO THE UDC TRIGGERS AUDIBLE AND VISUAL ALARMS. Indicate Yes or No 490-60. UDC LEAK ALARM TRIGGERS PUMP SHUTDOWN- Indicate Yes or No 490.61. FAILURE/DISCONNECTION OF UDC MONITORING SYSTEM TRIGGERS AUTOMATIC PUMP SHITIDOWN-Indicate Yes or No 490-62. 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 caved to monitor the interstitial space. 490-64b.LEAK WITHIN THE SECONDARY CONTATMENT OF UDC TRIGGERS AUDIBLE AND VISUAL ALARMS-indicate Yes or No 490.65. VII-I ELD 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/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). 490-66. TESTING OF SECONDARY CONTAINMENT COMPONENTS EVERY 36 MONTHS-Check the box if you have secondary containment that requires testing. 490-67. SPILL BUCKET TESTING-Check the box if you have spill buckets. 490-68a-h.VH[RECORDKEEPING-Indicate which monitoring and equipment maintenance records are maintained for flub facility. 490-69a IX TRAINING STATEMENT-Cheek 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 fudity. Note that the fust two items on the list mu.t be kept at the facility. 490-69b. MONITORING PLAN:Indicate thin this plan is kept w a reference document. 490-69c. OPERATING MANUALS FOR ELECTRONIC EQUIPMENT:Indicate that this plan is kept as a reference document. 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. 490-69£STATE WATER RESOURCES CONTROL BOARD(SWRCB)PUBLICATION- "HANDBOOK FOR TANK OWNERS-MANUAL AND STATISTICAL INVENTORY RECONCILIATION-Indicate that this is kept as a reference document. 490-699.SWRCB PUBLICATION:"UNDERSTANDING AUTOMATIC TANK GAUGING SYSTEMS":Indicate that this is kept as a reference document 490-69h.OTHER-Indicate that other reference documents are kept. 490-69i. SPECIFY-If"OTHER"is checked,enter abrief description of the other documeot(s)maintained at the facility.If additional space is needed,see Section X. 490-70. DESIGNATED OPERATOR TRAINING-Check this box to verify that this statement is trace. 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 monitoing-related information(e.g.,additional information required by your local agency). Attach any monitoring logs that you will be using for the monitoring of you tank system. 490.72. NAME-Enter the name of the person who mutinely conducts the manitoring and equipment maintenance under this plan. 490-73. TITLE- Enter the title of the person. 49044. NAME-Enter the name of tire second person,if applicable,who routinely conducts the monitoring and equipment maintenance under ibis plan. 490-75. TITLE- Enter the title of the second person. OWNER/OPERATOR SIGNATURE-The tank owner/operator,facility o,m,/opermor,or an authorized representative of the owner shall sign in the space provided. This signal=certifies that the signer believes that all information submitted is true,accurate,and wmplete,and that the training pmgmm 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 owner/operator,or an authoriud representative of the owner. 490-77. DATE-Enter the date the plan was signed. 490-78. APPLICANT NAME-Print or type the name of the person signing the plan. 490-79. APPLICANT TTTLE-Enter the title of the person signing the plan. UPCF UST-D(1212007)4/4