|
i •
<br /> (Agtmy Ute Onty) This;plan Ms bccn wY4 erd: A9p04M QAPDtOpad .4eC�Ya(�(tlbfle
<br /> Local Aprncy Silpratun.'
<br /> CMmmnss M Special Cama-o - -
<br /> UST Monitoring Plan—Page 2 InBtructious
<br /> Complete a Saparaee UST Monitoring plan for tach UST monitoring system at the feCiliW. This form must be submitted wish your told,] UST
<br /> Opetaiing Pe1Trllt Application and within 30 days of changes in the infmmarion it comems, Please note that your 10011 agency may roquirn you to
<br /> obtain apMval 13iior to installing or modifying monitoring equipment (Note. Numbering of thea iilsimcmiona follows the data elornent niAntbera on
<br /> ttee form.)
<br /> 490.54,MOfIITORIM OP THE t7NICI R DISPENSER CONTABJ'MFM-Rsdieatc the ou,000 user for LIM vanwring.
<br /> 490.146.SPEC&Y-if w-OVIW,is checked,o"crias Mars method Wes.
<br /> If V1-1-1,Vl-1.2 W In-1.5 er VL 1.99 is caeraeo,comocle 400-55 m 490.646_
<br /> 49035. PANFl.MANUPACRJRER-Emet me noun Of plc naalitaemtCT Of Ove ngNtosmS system rnrvrd pare)(wosolc). if i5 co e,novl purl(A.g.only an electrical
<br /> relay bole IF inotallW)14ave ibis space Nenle
<br /> 490.56, MODEL P- Pahv the model mmtber for fie 1ntni"wmem control paod(console).If there it ho Como)Panel(e0.,only tet electrical relay box a iMWkd)I®va
<br /> this
<br /> space www
<br /> 490.57. LEAXSENSM MANUFACTURER-Enter the nmr of the aunW)tonrtt of de aensor(s).
<br /> 490.58. MODEL 4(S)-Emu dr moan num6W efibl scm,ogs)infa110d.if ade monal space is needed,araC Sismich x.
<br /> 490.19. DETOMONOP A LEAK INTO THE UDC TRIGGERS AUDIBLE.AND VISUAL ALARMS. 7diease yea or No
<br /> 49060, UDC LIIAK ALARM TMOOERS PUMP SM.ITDbWN. 7ndkam Yes or No
<br /> 40x61. FAILURE/DISCONNECTION OF UDC MONMOKING SYSTEM TRIGGERS AUTOMATIC PUMP SHUTDOWN-Idt"Te yes or 170
<br /> 49062. 1=MONITORING STOPS THC FLOW OF PRODUCT AT THE DISPENSt -Indicate Yes or No.
<br /> 491665. UDC CONSTRUCTION- Idicahe if Ass commataon of the UDC is airylwwened-m double-walled,
<br /> 49064,DOUBLE-WALLED n4ril STrPlAL SPACE MONfTOR/NO- Inciicuc what is used m m CiW dee Imerxihal apace
<br /> 490.646,LEAK WMII t-I THE SECONDARY CONTAIMENT OF UDC TRIGGERS AUDIBLE AND VISUAL ALARMS-Indicate yes or NO
<br /> 49065. VILI£LD TESTING-(Reek pie boa if Y,u imw Gem roefled DY the Sparc WatOr ResowCK Connal HoarA(SWRCB)Uri me UST(a)Covered by®ir plan Iq,em
<br /> sub)en m 6ntannM[.ale fbactlan Regvaremnes(i,e..UST has any single-wan compost a ,
<br /> nd located within 1.000 Rem Ora public driNdr S waLr NU11
<br /> 490.66. TRItTWOOP S00061DwEV COMAINM627F=PONENTS E VERY 06 MONTHS-Check me box ifyoo have secondary mmainrram iaat rcq AM,Suring
<br /> A9067. SPILL BUCKET TESTING-Cbwk the box.if you Mw spill bockda.
<br /> 490.58,-h Vol RECORDX=PINO-Indkaa w a nwitsm irW and equipment malnr¢tanCe records me mahni iced rM this tleOby.
<br /> 490.69, DC TRAINING ST'ATEM04T-Check tie hoc to veAy than the suaement is mu
<br /> REFEItEN(S DO('UM6NIS MArNTAR72�AT PACILITY-Check disc appreprlate 0osan w aaeai6e reference documraa malnWrgd err she hciliy. Note chow rhe
<br /> &n two nems on the 1147 Cant le kept 0 this Wily
<br /> 4904ft MONrrQR[M PLAN!1ryl0aae rhd Our Wen n Rapt a a refirene,document.
<br /> 490691. OPERATINGMANUAL$FOR ELECTRONIC EQUfp%ENT'.ilamw para me plan a kepi as a reference donment.
<br /> 490-OL CA UST RROULATIONS-ladlem,rhar thio b kept a•IMrance,dec mem
<br /> A9669e. CA UST LAW-Indicate 16x1 she is kept Y a reticence dosvmmt.
<br /> 490-W--STATE WATER RPFeOURCES CONTROL HOARD(S WRCB)PUBLICATION- "NANDBOOK MRI-ANK OWNFp_q-MANUAL AND
<br /> STATISTICAL INVENTORY RECONCILIATION-Indicate that UNI is kept ice a referau docoea ss.
<br /> 496690.,SWRCD PUBLICATION,"UNDERSTANDING AUTOMATIC TANK GAUGING SYSTEMS":4diaak,tat this is kept as a reference docmedr.
<br /> 49069h OTHER-Pudiate that other cavi :me documerm are kept
<br /> 49069L SPECIPY-11''OTIMC is ehcdcad,ever a brid4c cription of the other documents)miontatoed at dre facility.IfadWrtaul epeee la needed,sae.Se .X.
<br /> 190.70. DESIGNATED OPESATOR TRAD41NO-Choose this box m..ity MM itis sraamem is vie.
<br /> 49671. COhm4SLTTS/ADDFIIONAL MPORMATTON-Mute slci000d coomahus or you may W.-h art 1derely th1 nnm69r of cklitiooal Pages ofinformstion to dolanbe
<br /> am addhlMW UST 6yltem moniroring-roles fntaharemloa(CA.,Additional infor osrion nelosred by your local agency). AraCh sola rnontter0f8 bps Nat Yeu will lie wu.g
<br /> PorrM nwtitorLry Rrww Toa IYmeaa
<br /> 49672. NAME-Enter ma:mome of the person who roWrrly eoaduess the menlmnn,and equpmam mumecon—wider this plan
<br /> 490673. TITLE. Einer the line of dm person
<br /> 49674. NAME-quer tie came ofne x,mdpmsoq IEeppilmhle,wW roInmely rmWunt not monitoring and OgUipmenr nulmenmoc uNler this dao,
<br /> Ap0-75. TrrLE, never the ulk of am saver pesao9
<br /> OWNER/OPERATOR SIONATIIRE-The took ownedopeawr,gtalimy owner/opuamr,or M arlmtimd ropeamupve of tea owner shall sign in tM apaea provided,
<br /> This alparush omriEes eat the si&r,bdiwes mai ail inrOmanon u4nu ied is true,accurate.and Complete,and mar the training purlins,spedifW in Seamon IX Iw
<br /> lime anpla omed.
<br /> A9676. REPRESENTING-Cheek tM 4ppropriehc boa to irdime v,o,"r Pte stPpn is the UST MMCIIppetatM,the UST Denny ownar/oparamv,or ae
<br /> adhodxod teposeatarive Of to Owner
<br /> 490.17. DATE-gnaw the dare Ur plan war sigrrd.
<br /> A90,78. APPLICANT NAME-Prim w typo Ibe name of me peWn alenarg die plan
<br /> 490-79. APPLICANT T[TU-Law the rine of ds person algadag the plan
<br /> ,PCF(IST-13(#/2007)4M
<br /> 60/L0 39)Vd SEE9 CD6V SVDWA A 8L0f84660i» IZ:ZT 800?/L4/BB
<br />
|