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Mr (Agency Use Only) This plan has been reviewed and: I}I•Approved ❑ Approved With Condo, s �p Local Agency Signature: m - N1104 -i Date: 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 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 ANDER DISPENSER CONTAINMENT- Indicate the method used for UDC monitoring. 490.546. SPECIFY -If 99 "Other" is checked, describe other method used. If VI -1-1, VI -1-2 or VI -1-3 or VI -I-99 is checked, complete 490.55 to 490-64b. 490.55. PANEL. MANUFACTURER—Enter the name of the manufacturer of the monitoring system control panel (consi 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 control panel (e.g., only an electrical relay box is installed) leave this space blank. 490.57. LEAK SENSOR MANUFACl'URER— Enter the name of the manufacturer of the sensor(s). 490.58. MODEL #(S) —Enter the model number of the servants) 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 SHTTDOWN- Indicate Yes or No 490-61. FAE.URE/DISCONNECTION OF UDC MONITORING SYSTEM TRIGGERS AUTOMATIC PUMP SHUTDOWN- Indicate Yes or No 490-62. UDC MONITORING STOPS THE FLOW OF PRODUCT AT THE DISPENSER - Initiate 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 whaz is used to monitor the interstitial span. 490-64b. LEAK WTTHINTHE SECONDARY COMAIMEM OF UDC TRIGGERS AUDIBLE AND VISUAL ALARMS - Indicate Yes or No 490-65. VII -I ELD TESTING -Check the box if you have been notified by the State Water Resources Control Board(SWRCB)dust the UST(s) covered by this plan ista, subject to Enhanced Leak Detection Requirements (i.e., UST has any single-wall component and is lowed 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. VIII RECORDKEEPING -Indicate which monitoring and equipment maintenance 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. Note that the fust two items on the list = be kept az the facility. 490-69b. 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 W 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 490-69E 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. 490-69g. SWRCB PUBLICATION: "UNDERSTANDING AUTOMATIC TANK GAUGING SYSTEMS": Indicate that this is kept as a reference document. 490-691L OTHER - Indicate that other reference documents are kept 490-69i. SPECIFY-If"OTHER"is checked, enter a brief description of the other documarl(s) maintained at the facility. If additional space is needed sen Section X. 49040. DESIGNATED OPERATOR TRAINING - Check this box to verify that this statement is true. 490-71. COMMENTS/ADDMONAL INFORMATION— Make additional comments oryou may attach and identify the number of additional pages of information to describe my additional UST system monitoring -related information (e.g., additional information required by your local agency). Attach any monitoring logs Wit you will be using for the monimring of your tank system. 490-72. NAME— Enter the name 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 mune of the second person, if applicable, who routinely conducts the monitoring and equipment maintenance under this plan. 490.75. TITLE - Enter the title of the second person OWNERIOPERATOR SIGNATURE —The tank owner/operator, facility owner/operator, or an authorized representative of the owner shall sign in We space provided. This signature certifies that the signer believes that all information submitted is tae, accurate, and complete, and 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 owner/operator, or an authorized 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 TITLE— Enter the title of the person signing the plan. UPCF UST -D (12/2007) 4/4