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(Agency Use Only) This pia r - e If7./approved ❑Approved With Conditions ❑Disapproved Local Agency Signature �_CDate: 7��e s'. t Comments or Special Condi 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. 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 VW- L VI-1-2 or VI-1-3 or VI-1-99 is checked,complete 490-551.490-64b. 490-55. PANEL MANUFACTURER-Enter the name ofthe manufacturer of the monitoring system control proal icoamle). 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. 49057 LEAK SENSOR MANUFACTURER-Enter the name of the manufacturer ollhe sensogs). 490-58. MODEL#(S)-Enter the model number of the sensoria)installed.If additional space is eedCd,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. FAILUREIDISCONNECTION 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. 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 used to monitor the interstitial space. 490-64b. LEAK WITHIN THE SECONDARY CONTAINMENT OF UDC TRIGGERS AUDIBLE AND VISUAL ALARMS-Indicate Yes or No. 490-65 VII-1 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 Bare subject to Enhanced Leak Detection Requirements it 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 ifyou have secondary containment that requires testing. 490-67 SPILL BUCKET TESTING-Check the box if you have spill buckets. 490-68. VIII RECORDKEEPING-Indicate which monitoring and equipment maimcuance records are maintained forthis facility. 490-69a. IX TRAINING STATEMENT-Check the box to verity that the statement is Ime. REFERENCE DOCUMENTS MAINTAINED AT FACILITY-Check the appropriate boxes to describe reference documents maintained at the facility. Note that the ftrsl two items on the list IDOS.t be kept at 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 as a reference document, 490-69d.CA UST REGULATIONS-Indicate that this is kelt as a reference document. 490-69e. 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. 490-69g. 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 a briefdescnption of the other documents)maintained at the facility.Ifadditional space is needed,see Section X. 490-70, DESIGNATED OPERATOR TRAINING-Check this box to verify that this statement is tee. 490.71. COMMENTS/ADDITIONAL INFORMATION -Make additional comments or yon 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 that you will be using for the monitoring ofyour tank system 490-72 NAME-Enter the name ofthe person who routinely conducts the nenitorfng and equipment maintenance under this plot. 490-73. TITLE-Ent the title ofthe person. 490-74. NAME-Enter the name ofthe second person,ifapplicable,who routinely conducts the monitoring and equipment maintenance under this plan. 490-75. TITLE-Enter it.title of the second person. OWNER/OPERATOR SIGNATURE-The tank owner/operator,facility owner/operator,or an authonzed representative of the owner shall sign 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. 490-76. REPRESENTING - Check the appropriate box to indicate whether the stbmer is the UST owner/operator, the UST facility owner/operator. or an authorized representative ofthe owner. 490-77 DATE-Enter the date the plan was signed. 490-78. APPLICANT NAME-Print or type the name ofthe person signing the plan. 490-79. APPLICANT TITLE-Enter the title ofthe person signing the plan. UPCF UST-D(12/2007)-4/4 www.unidoes.org