COMPLIANCE INFO 2010-2012 - Laserfiche WebLink

Home Browse Search

(Agency Use Only) This plan has been reviewed and: ❑Approved �-I%Approvad With Conditions ❑Disapproved Laval Agency Signature; /f c1_� _ Date: ,ate. �S /C)� Comments"Special Condoi UPCF 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. MONITOR ING OF THE UNDER DISPENSER CONTAINMENT-Indicate the methal used for UDC mmit«ktg. 490-54b.SPECIFY-If 99"Other"is checked,describe other method used. If VI-I-I,VI-1-2 Or VI-1-3 or VI-1-99 is checked,compute 490-55 m 490-64b. 490-55. PANEL MANUFACTURER-Enter the name of the manufacturer of the monitoring Mum camml panel(convole). If them is no caotrol panel c.g.,only an elec neI relay box is installed)leave this space blank- 490-56. MODEL p-Enter the model number for the monitoring system control panel(console).If dam is to control panel(e.g,only an electrical relay box is inatalledl leave this,puce blank. 491.57. LEAK SENSOR MANUFACTURER-Enter the name of the manufacturer ortaxenw(s). 49-58 MODhLa(S)-Enter the model number of the sciaals)installed.If additional space is needed,use Section X. 491-59. DETECTION OF A LEAK INTO THE UDC TRIGGERS AUDIBLE AND VISUAL ALARMS. Indicate Yes or No. 491-60. UDC LEAK ALARM TRIGGERS PUMPSHUTDOWN-Indicate Yes or No. 490.61, FAILURE/DISCONNECTION OF UDC MONITORING SYSTEM TRIGGERS AUTOMATIC PUMP SHUTDOWN-Indicate Yes or No. 491-62, LDC MONITORING STOPS TI IE FLOW OF PRODUCT AT THE DISPENSER-Indicate Yes or No. 491-63. LDC-CONSTRUCTION-idicate ifnhe construction of the UDC is single-waged,ordouble,"lled. 491-64a. DOUBLE-WALLED INTERSTITIAL SPACE MONITORING-Indicate what is used to monitor the intestinal space. 490-64b.LEAK WITHIN THE SECONDARY CONTAINMENT OF UDC TRIGGERS AUDIBLE AND VISUAL ALARMS-indicate Yes or No 491-65. VII-I FLO TESTING-Check the box if you have been notified by the Stata Water Resonances C'omrol Bound(S WRCB)that the USTO)covered by Ni,plan Wine subject to Enhanced Lmk Detceti at Requimment(it..UST ban any single-wall component and is Insured within 000 Fat of a public drinking water well). 49LL66. 'TESTING OF SECONDARY CONTAINMENT COMPONENTS EVERY 36 MON THS-C.heck the box if you have secondary containment shut requires spring. 491-67. SPILL BUC'KETTESI1NO-Check the box ifyou have spill bucket. 491-68. V III RECORDKEE PING-I nleare which monitoring andequipman mairaenance records we muimmined for m is facility 49069a. IX TRAINING STATEMENT-Check nib box m verify that the staemem is nue. REFERENCE DOCUMENTS MAINTAINED AT FACILITY-Check the appropnate boxes to describe reference documents maintained at the facility. Note that the first two items on the list must be kept at she f tility. 490.696. MONITORING PLAN:bdmme that this plan is kept as a referenee document. 490,-69c.OPERATING MANUALS FOR ELECTRONIC EQUIPMENT:I"&wic that this plan is kept a,a reference document. 490-69d.CA UST REGULATIONS-Indicate thin this is kept as a reference document. 49669.. CA LST LAW-Indicate data this is kept as a nforence document. 49-69f STATE WATER RESOURCES CONTROL BOARD(SWRCB)PUBLICATION- "HANDBOOK FOR TANK OWNERS-MANUAL AND STATISTICAL INVENTORY RECONCILIATION":indicate that this is kept axis reference document. 490-69g, SWRCB PUBLICATION:"UNDERSTANDING AUTOMATIC TANK GAUGING SYSTEMS":Indicate that this',kept as n rcfemnce dommmt. 490-69h.OTHER-Indicate that other reference documents we kept. 491-69i. SPECIFY-If"OTHER-is checked,enter a brief description of the other do:ummt(s)maintained at the facility.if additional space is needed.am Section X. 490-70. DESIGNATED OPERATOR TRAINING-Check this aox o verify that this statement is trac. 490-71. COMMENTS'ADDITIONAL INFORMATION-Make additional comments of you may attach oil identify the number of additional pages of information to de. ibe any additional UST system mrnitonm0-reWed information(e.g.,addition.)information required by your local agency). Attach any monitoring logs that you will be oving for the monitorintank g of yew system 49]-72. NAME-Enter the name of the person who maturely conducts the monitoring and equipment maintenance untktits, Plan. 491-73. TITLE-Enter the tine of the person. 490-74. 491.75. TAME- Enter the name of the second person,if applicable,who routinely conduct,db monitoring and equipment ntintmmcc under this plan. Enter the tide of the acco d Person, OWNER/OPERATOR SIGNATURE-The tank owner/uperans,f«illy owner/apeman,or an authorized reprpemaive of she owror shill sign in she space provided. this signature certifies dist the signs beaevp that all Information submitted is rum,accurate,and been hoperneurd. complete,and that the training program specified in Section IX has 490-76. REPRESENTING - Check the appropriate box we indicate whether the signer is the UST ownerlopenmr, she UST faciiity owner/operator, or an authorized npmarnunivc of the owner, 490-77. DATE-Eater the dab the plan was signal, 490-7K APPLICANT NAME-Pont m type she name of the parson signing the plan, 490-79. APPLICANT TITLE-Enter the title of the Perste signing the plan. OPCF UST-D(1212007).414 www.apid«,.erg