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(Agency Use Only) This plan viewed�'� Approved ❑APpmved w' n Local Agency Signature; Comments or Special Conditions: Date G{ ' UST Monitoring Plan—Page 2 Instructions Complete a separate UST Monitoring plan for each UST monitoring system at the facility. Operating permit Application and Within 30 days of changes in the information it contains, Please note that your local agency may ry. This form must u submitted with your initial UST obtain approval prior to installing or modifying monitoring equipmenL (Note; Numbering of these instructions follows the data element numbers on the form.) Y require you to 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 VL1-1,VI_I.2 or VI-1-3 or VI-1-99 is checked,complete 490-55 to 490-64b. 490-55. PANEL MANUFACTURER—Emer the name of the menuf=mrer ofthe monitoring system control panel(console) If them is no control relay box is installed)leave this space blank. 490-56. MODEL#- Enter the model number for the monitoring Panel(e.g„oNy an electrical this 8 system control panel(console).If Metals no control (1.9., space blank panelonly an electrical relay box is installed)leave 490-57. LEAK SENSOR MANUFACTURER—Enter the name of the manufacturer of the sensor(s). 490-58. MODEL#(S)—Enter the model number of the seasons)installed.If additional space is needed,we IndicatYes or No dicate Yes or No e Section X. 490.59. DETECTION OF A LEAK INTO THE UDC TRIGGERS AUDe 490.60. UDC LEAK ALARM TRIGGERS PUMP SHUTDCIWN- In ®LE AND VISUAL ALARMS 490-61. FAILURE/DISCONNECTION OF UDC MONITORING SYSTEM TRIGGERS AUTOMATIC PUMP SHUTpOWN_ 490-62. UDC MONITORING STOPS THE FLOW OF PRODUCT AT THE DISPENSER-Indicate Ye or No. 490-63. UDC CONSTRUCTION- Indicate Yes or No 490.64a DOUBLE-WALLED Indicate if the cOnamsytien of the UDC is single-walled or double-walled. 490.64b.LEAK INTERSTITIAL SPACE MONITORING- Indicate what is used to am my the interstltiel space. WITHIN THE SECONDARY CONTAIMENT OF UDC TRIGGERS AUDIBLE AND VISUAL AL 490-65. Subj to TESTTNG-Cheek the box if You have been notified by the State Water Resources Control Board(SWRCB)that the UST(s)covered by this plan is/ere subject ro Enhanced Leak Detection Requirements(i.e.,UST has an sin e- ARMS I)that Yes or No 490-66. TESTING OF SECONDARY CONTAINMENT COMPONENTS EVERY 36 MONTHS component is located within 1,000 fat of a public drinking water well). 490-67. SPILL BUCKET TESTING-Check the box ifyou have spill buckets Check the box if You have second ary 490.6ga-h.VIE RECORDKEEPhNG-Indicate which monitoring and equipare ment maintenance records maintained for this facility. containment that requires testing. 490-69a IX TRAINING STATEMENT-Check the box to verify that the statement is true. REFERENCE DOCUMENTS MAINTAINED AT FACILITY a refe — fiO two items on the list Rilla 490-69b. MObe kept at the facility. Check the appropriate boxes to describe reference documents maintained at the facility. Note that the MONITORING PLAN:Indicate that this plan is kept as rence document. 490.69c. OPERATING MANUALS FOR ELECTRONIC EQUIPMENT;Indicate that this plan is kept az a reference document, 490-69d. CA UST REGULATIONS-Indicate that this is kept ss 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 RECONCILLA77ON-Indicate thN this is kept as a reference document 490-69g.SWRCB PUBLICATION:"UNDERSTANDING AUTOMATI 490-6911.OTHER-Indicate that othrs reference documents are kept. C TANK GAUGING SYSTEMS":indicate that this is k eg a referent"490-69i. SPECIFY-If"OTHER"is checked,enter a brief description of the other docummgs)maintained at 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/ADDMCNAL INFORMATION—Make additional comments or you may attach and identify the number of additional Pagan of infatmation to describe any additional UST system msyste g-related for the monitoring of your tankk system imbrmation(e.g,additional information required by your local agency). Attach any monitoring logs that you will be using 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 monin,n and a ui 490-75. TITLE- Enter the title of the second person. OWNEWOPERATOR SIGNATURE_ 8 q pment maintenanc<under this plan. This signature certifies that the signer believes h tall informationfsubmined is truility e, end wmOr.Or an Ixul representative and entthatattiive of the owner shall sign been implemented. gram gn in the space provided. 490-76. REPRESENTING—Check the appropriate box to indicate whether the signer is the UST owner/operstor,the UST facility owneUom sWilled m Section IX has authorized representative of the owner. 490-77. DATE—Enter the date the plan was signed. ry Demtor,or an 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 ..