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(Altswy Use 04W This plan has been reviev end: .-. +LPpOVOd ❑Approved W' C6pdb10as. . i LOW Agetrcy Signatdre: ��—/ Dateej 2,0196 Comments a Special Catelftionsc. 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 now 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 tmilpd used for UDC monitoring. 490-54b.SPFPZY-If 99"Othef'is checked,describe Other method used. If V1-1-1,Vf-1,2 or VI-1-3 or V1.1.99 is checked,complete 490,55 to 490-64b. 490.55. PANEL MANLIPACTIIRPR.Enter rix nuns,ofthe manufacturer Oft"momtonng system coastal panel(console). If there is no control panel(a.g„only an electrical relay box is installed)leave this apace blank 490,56. MODEL at- Lmcr Oa model number for fie momlOring system control panel(console)If dam is On Control pawl(e.g.,only an electrical relay Dux is metalled)leave this Space blank. 490-57. LEAK SENSOR MANUFACTURER-Enter the name ofthe mnnuf outer of fie semor(s). 490-58. MODEL M(S) Enter it=model number ofthe sensors)installed.Ifadd nonal space is rkeded,use Section X, d90.59. DETECTION OF A LEAK INTO THE UOC TRIGGERS AUDIBLE AND VISUAL ALARMS. Indicate Yes or No 490-60, UDC LEAK ALARM TRIOCFRS PUMP SHUTDOWN. Indicate Yes or No 490-61. FAILURE/DISCONNECTION OF UDC MONITORING SYSTEM TRIGGERS AUTOMATIC PUMP SHUYDOWN-Indicate Yea or No 490.62. UDC MONITORINO STOPS TM FLOW OF PRODUCT AT THE D1SeENSLR-Indicate Yes or No. 490-63. UDC CONSTRUCTION- Indicme ifthe eomh wdon of the UDC is singlewalled.or double-wallod. 490-64a DOUBLE-WALLED INTERSTITIAL SPACE MONITORING- Indicate watt is laed to monitor the maellitial Space. 490.64b,LEAK WITHIN THE SECONDARY CONTAIMENT OF UDC TRIGGERS AUDIBLE AND VISUAL ALARMS-Indicate Yes or No 490-65. V IULD TESTING-Check the box ifyuu have been notified by the Stan Wsmr Resources Conte]Broad(SWRCB)that the UST(s)covered by this plan islare subject to Enhanced Leak Detection Requirements(i.e..UST has any 111191 . all 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 if you have Secondary containment that requires testing. 490.67. SPILL BUCKET TESTING-Check the box ifyuu have spill buckets. 490-68a-h.VIII RECORDKLLPING-Indicate WncIl awnituring and equipmem maintenance records are maintained Lor this facility. 491169& IX TRAININO STATEMENT-Check rhe box to verify that the statement is nue. REFERENCE DOCUMENTS MAINTAINED AT FACILITY-Check the appropriate boxes to describe reference documents maintained at the facility. Note that the fits(two items on the list MW be kept at the facility, 490-606. MONITORING PLAN:Indicate that dds plan is kepi as a reference document 490d9c. OPERATING MANUALS FOR ELECTRONIC EQUIPMENT:Indicate that this plan is kept Se a reference document. 490-69d. CA UST RHGULATIONS-lvdic.ste due dtu is kept as a reference d0cumem. 490-69c. CA UST LAW-Indicate that this is kept u a refereaCe document. 490-69£STATE WATER RESOURCES CONTROL BOARD(S WRCB)PUBLICATION- "HANDBOOK NOK'1'ANK OWNERS-MANUAL AND STATISTICAL.INVENTORY RECONCILIATION-indicate that this is kept as a reference doeontem. 490-69g,S WRCB PUBLICATION'"UNDERSTANDING AUTOMATIC TANK GAUGING SYSTEMS":IrdiWt that this is kept ag a reference docunmnl. 490-69h.OTHER-Indicate that other mit rmee doeumcats are kept. 490-69i. SPECIFY-If"OTHER'is checked,enter a brlefdGscrilrTton Of the oder docum %S)maintained at the facility,If additional Space is needed,See Section X 490-70, DESIGNATED OPERATOR TRAINING"Check this box to verify tram this statement is nue, 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 mannoring-relased information(C.g.,additional infomution required by yaw local agency). Attach any monitoring logs feat you wrlh be using tarda Mounting of Yom lack system. 490-72. MANE—Ener the name of the person who routinely conducts the monitoring and c laipment maintenance under this plan 490-73. TITLE. Enter the title of the persum 490-74. NAME—Ener the name of rhe second person if applicable,who routinely conducm rite monitoring and aquipaem maintenance under this plan, 400.75. TDT.E, ismer the title of da second person OWNEWOPERATOR SIGNATURE—The sank owner/operator,taoilily owner/operator,Of an amhoriwd representative of she Owner shall sign in The space provided. This signature certifies that the siguen beliwn mat all informentm submitted is We,aceurMe,and Complete,and that the training program specified in Section IX has been mplemented. 490-76. REPRESENTING—Check the appropriate box 10 indicate wremar the sipper is the UST Olvaer/operator,the UST faeiliry owner/operator,or an authorised representative of the owner. 490.77 DATE—anter the date the plan eat signed. 490-78. APPLICANT NAME—Print w type the name of the person Signing the plan. 490-79. APPLICANT TrTLE—Doter the tine of the person signing the pica IiPCF UST-D(12/3007)4/4 60/LO 39Vd SE69 0088 SVD9IVA A 8TOEOV66OZ TZ:ZT 800Z/LZ/80