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(Agency fGe UnO'1 This plan hm been reviewed and: ❑Approved ❑Approved With Conditions Local Agency Signature: Comments car Special Conditions:'� ---------. .`Dale; 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 initis! UST Operating lain Permit Application and within 30 days of changes in the information it contains- Please rate that your kxal agency may require you ro Obtain approval prior to installing or modifying monitoring equipment- (Note_ Numbering of(hose Instructions follows Use data clement quire you on rbc form.) 49454&MONITORING OF TftE UNDER DISPENSER CONTAINMENT-Indirale the method used for UDC monrmrmg 49454'.SPECMY-I(99.Othef'is dwck A describe other method used. 49455. If VI.1.1,MANUFACTURERVl-1-2 or VI-I.3 Or VI.1-99 is checked.Complete 490.55 to 490.64b. 1041Tthis Space the name of de meaufactuon of the monitoring system control panel(cnmole). If there u no control rolsy box is installed)leave dna space blank. 49456. MODEL.8- Ener the model member far the monihorin panel(e.g„an1Y an elxtriwl this a system canW panel leerele).Jr lb=is no control panel(e.g.,only an electrical relaybo Voice blank. xis insWled)leave 49457. LEAK ESENS MANUFACTURER-Enter the same ofdcmaouiacmrea of the 4945& d( ) the model number of the sero 49459. DETECTION OF A LEAK INTO ERSTHE t(s) installed If additional space is needed,use Silvan X 490-60. UDC LEAK ALARM IO UDC TRIGGERS AUDIBLE AND VISUAL ALARMS. lndirareYes or No 49661, FAIL PUMP SHUDC UTDOWN WN- Indicate Yea or No ySTEM 490.62. UDC MONITORING STOPS THE FLOW OFF PRODUCT AT THE D DISPENSER Indlwe Yea oWERS AUTOMATIC r�SHUTDOWN.Indicate Ym or No 49043. UDC CONSTRUCTION. Indicate ifthe corrmcdon of the UDC is ISPEwSER-allcct ordicate waned. 490,64e.DOUHt.&WALI.Ep INTERSTITIAL SPACE MONfTORING- Indicate what is used to monitor the i sen trinal space. 49t1-64'.LEAK WITHIN THE SECONDARY CONTAIMENT OF UDC TRIGGERS AUDIBLE AND VISUAL,ALARMS-Indicate Yas or No 49665. VI-I BLD TFi$TINO-Cheek We box if you have been VST h by y State WsrarResources Control Board(SWRC9)thtl the UST(a)covered by this plan is/am duDjett Io Enlwc4d Leak Detection icoquitements(f.e.,VST has any singlo-wall cation and is located within 1,000 frit of a public drinking water..ell). 49 TTESTING OF SECONDARY CONTAINMENT COMPONENTS EVERY 36 MONTHS-Check the box if you have secondary vontainmem that w 49667. SPILL BUCKET TESTING-Check the box if you have spill buckets. 49"Ire-h.VIII RECOROKMING.Indicate which mootment requires Ming. 490-6% IX TRAINING STATEMENT.Check the box to verity Chet the raWnmtinftns Inruece accords are tnemtamcd for tfiis feciliry. I'mRCFtwo DOCUMENTS the list MU MAINTAINED ql'FACILITY-Check the Vproprues box"to describe rofertoce dxurrlents maintained et the facili Note hOt two nems on the list aIYB e t kept tl the facility. 494696. MONITORING PLAN:Indicate that ads plan is kept az a reference documern. Ty tiro 49469c. OPERATING MANUALS FOR ELECTRONIC EQUIPMENT 49069d CA UST REOULATTONS.Indicate that Nis is k tome : a case that this plan is kept as a re(emce docruaen[ 496-69e. CA LIST LAW-Indicate that thje is k � e cumene document, 49469!.STATE WATER RESOURCES CONTROL �tbcWRC STATISTICAL INVENTORY NTROL BOARD(I WRCB)PUBLICATION- "HANDBOOK FOR TANK OWNERg.MANUAL AND 490.69 S RECONCILIATION-Indicate Net this is kept r a eefertoce danrmem, 1 WRCB PUBLICATION:"UNDERSTANDING AUTOMATIC TANK GAUGING SYSTEMS":lntticate spar skis is kap as a refererce document, 490 i9 SPEECIIFFY Judicata that oyer eke(L en documems erekep SPECIFY-If TRAINING ter abrief this box to nreother dceemabruerraintae tl the facility.Ifadditionals a947o. DESIGNATED 49477. COMMENTS/ADDTTIONAL INFORMATION- ` �thy this staeement u sue. is needed,sot Section X. any additional UST Mk,n(,tr nsit constraints or You may tltech and identify the number of additional Por the monitoring of your bulk 1sYstem related int'rmaDon(a.g,additioral information required by your local agency). Attach env monitoring toring log,rrnaD Grp describe 49471 NAME-Enter the name of lbe person who roup 6 ofs Y will be using 49473. TITLE- Enter the title of the person t�Y and s the monitoring suit equipment maintenance under this Ian 49474. NAME-Enter the P . 49475. TITLE. itic,tf the ound pp if appliraDla.cant routinely urine conducts the monitoring and equipmem maiatenmlce tinter this plan. Enter the title I the second �' OWNS plionnItATOR SIGNATURE-The lank owtp/opemor.facility owner/operator.or m aurbonzed representative of the owner shalt sign o the This signature rermim that the signer believes that all infombmon submitted is Ime,stearate,and complete,and that this,paining prpgrmn specified space provided. been impienaprtao, REPRESENTING Check the appmpinte box m i pacified in Section IX has authorized tepesentative of The owner. indicate whether the siprer is the UST owner/operator,the UST fecifity owner/v 490.7). DATE-Eos the date the Alen was',g ed. Ptrator,or M 49478, APPLICANT NAME-Print or rype the rine of Ile person signiug the plm 49479. APPLICANT TITLE-Einer the true of the person signing the plan. UPCF UST-0(t2/2W7)4/4