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� rn/ (4genev Use Only) This plan has been9A C1reviewed an � )Pproved Approved With Conditions ❑Disapproved Local Agency Signature: I/� / l s�C- l 3 �� Date q Comments or Special Conditions. UPCF UST Monitoring Plan— Page 2 Instructions Complete a separate UST Monitoring Plan for each Usf 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 UNDER DISPENSER CONTAINMENT-Indicate the method used for UDC monitoring 190-54b SPECIFY-If 99"Other"is checked,describe other method used. If VI-1-1,VL-1-2 or VI-1-3 or V1-1-99 is checked.complete 490-5510190-Wb. 190-55 PANEL MANUFACTURER-Enter the mann of the manufanurer ot'the monitoring system control panel(console). If there is no control panel(eg.,only an electrical relay box is installed)leave this space blank. 190-56 MODEL j-Enter this model number for the monitoring system control panel(console).If there is to control panel(eg.,only an electrical relay box is installed)leave this space blank. 190-57 LEAK SENSOR MANUFACTURER-Enter the name ofthe manufacturer of The senaxi 190-58 MODEL B(S)-Enter the meMel numberof the seasons)installed.Wadi space is needed,me Section X. 190-59 DETECTION OF A LEAK INTO THE UDC TRIGGERS AUDIBLE AND VISUAL ALARMS. Indicate Yes or No. 490-60 UDC LEAK ALARM TRIGGERS PUMP SHUTDOWN-Indieale Yes or No. 190-61. FAILURE/DISCONNECTION OF UDC MONITORING SYSTEM TRIGGERS AUTOMATIC PUMP SHUTDOWN-Indicate Yes or No. 190-62. UDC MONITORING STOPS THE FLOW OF PRODUCT AT THE DISPENSER-Indicate Yes or No. 190-63 UDC CONSTRUCTION-Indicate if the construction of the UDC is single-walled.or double-walled. 490-63a DOUBLE-WALLED INTERSTITIAL SPACE MONITORING-Indicate what is used to monitor the interstitial space. 190-641, LEAK WITHIN THE SECONDARY CONTAINMENT OF UDC TR[GO ERS 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)that the UST(s)covered by this plan ware subject 10 Enhanced Leak Detection Requirements(i.e..USI'has any single-wall component and is located within 1,000 feet ofa 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 bore if you have spill buckets 490-68 VIII RECORDKEEPING- Indicate which manioring and equipment maintenance records are maintained for this facility. 190-69a. IX TRAINING STATEMENT-Check the box to verify that the statement is true REFERENCE DOCUMENTS MAINTAINED A FACILITY-Check the appropriate boxes to describe reference documents maintained at the facility Note that the first two items on the list must he kept at the facility. 190-69b 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"a reference document. 490-69d. CA UST REGULATIONS -Indicate that this is kept as a reference docunant. 49"9e CA UST LAW-Indicate that this is kept as a reference document. 490-69f 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 m a reference document. 490-69h.OTHER-Indicate that other reference documents are kept. 490-69i SPECIFY If"OTHER"is checked,enter a bnefdeseriprion of the other documents)maintained at the facility (faciditional space is needed,see Section X. 490-70 DESIGNATED OPERATOR TRAINING Check this box to verify that this statement is true. 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 monitoring-related information(eg..additional information required by your local agency) Attach any monitoring logs that you will be using for the monitoring of your tank system 19(1-72 NAME-Enter the name ofthe person who routircely conducts the monitoring and equipment maintenance under this plan. 490-73 TITLE Enter The title of the person. 490-74. NAME-Enter the tame of the second person.if applicable,who muamh,conducts the monitoring and equipment maintenance under this plan. 490-75 TITLE-Enter the title of the second person. OWNER/OPERATOR SIGNATURE -'rhe tank owner/operator,facility owner/operator,or an authorized representative of the owner shall sip 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 IX has been implemented. 190-76 REPRESENTING - Check the appropriate box to indicate whether the signer is the LIST owner/operator, the UST facility owner/operator. or an authorized representative of the owner. 490-77 DATE-Enter the date the plan was sigmd. 490-78 APPLICANT NAME-Print or type the name of n person signing the plan. RECEIVED 190-79 APPLICANT TITLE Enter the line aYtln person signing the plot. JAN 1 520113 SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT L'PCF LST-D(12/2007)-4/4 www.unidms.org