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A (4w ry Use On/y) This plan has been reviewed d Approval ❑Approved With Conditions q ❑Disapproved Local Agency Signature. - Date: . /.5 Comments or Special Conons' C/ 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-'Othef'is checked,describe other method used. If VI-1-I,VI-1=or Vl-I-3 or Vl-I-99 is checked,complete 490-55 to 490-646. 490-55. PANEL MANUFACTURER-Enter the name of the manufacturer ofthe monitoring system control panel(console). If there is no control panel(c.g_,only an elecMcal 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 contrail panel(e.g-,only an electrical relay box is installed)leave this space blank. 49057. LEAK SENSOR MANUFACTURER-Enter the name of the manufacturer of the sensonsk 490-58. MODEL#(S)-Enter the model number of the sensors)installed.If additional space is needed,use Semon X. 490-59. DETECTION OF A LEAK INTO THE UDC TRIGGERS AUDIBLE AND VISUAL ALARMS. Indicate Yesor 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 constriction of the UDC is single-walla 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-I ELD TESTING-Check the box if you have been ratified by the State Water Resources Control Board(SWRCB)that the UST(s)covered by this plan mare subject to Enhanced Leak Detection Requirements(i.e.,UST has any single-wall component and is located within 1,000 feet of public drinking water well. 490-66. TESTING OF SECONDARY CONTAINMENT COMPONENTS EVERY 36 MONTHS-Check the box if you have secondmv containment that requires testing. 490-67. SPILL BUCKET TESTING-Check the box if you have spill buckets. 490-68. VIII RECORDKEEPING-Indicate which nonstaining 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 desenbe reference documents maintained at the facility. Note that the first two items on the list must 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 kept as a reference document. 490-69e. CA UST LAW-Indicate that this is kept as a reference document. 490-69f STATE WATER RESOURCLS 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 chocked,enter a brief description of the other documents)maintained a the facility,if additional 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 identity the number of additional pages of info r ation to describe any additional UST system monitoring-related information To 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 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 name of the second person,if applicable,who routinely conducts the monitoring and equipment maintenance under this plan. 490-75. TITLE-Eater the tide of the second person. OWNER/OPERATOR SIGNATURE-The tank owner/operator,facility owner/operator,or an authorized 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. 491 REPRESENTING - Check the appropriate box to indicate whether the signer Is the UST owner/opemtor. the UST facility owner/operator, or an authonzed representative of the owner. 49047. DATE-Enter the date the plan was signed. 490-78. APPLICANT NAME-Print or type the name of the person signing the plat 490-79. APPLICANT TITLE-Enter the title of fix person signing the plan. UPCF UST-13(12/2007)-4/4 www.unidocs.urg