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(Agency se Only) This plan has been reviewed and: ❑Approved D Approved With Conditions Local Agmey Signature: CDmrnenl s or Special Conditions: Date: UST Monitoring Plan—Page 2 Instructions COmplett a separate UST Monitoring plan for each UST monitoring system at the facility. This form must be submitted with your initial LIST Operatin Permit Application and within 30 days of changes in the information it contains. Please note that your local agency may require you to obtain ap roval phor to installing or modifying monitoring equipment. (Note: Numbering of these instructions the form. follows the data element numbers on 490-54a,IV ONITORING OF THE TINDER DISPENSER CONTAINMENT-Indicate the method used for UDC monitoring. 490.54b.S ECIFY-If 99"Other"is checked,describe other method used. If -1-1,VI-1-2 or VI-2-3 or VI-I-99 is checked,complete 490-55 to 490-64b. 490-55, P L MANUFACTURER—Enter the name ofthe manufacturer ofthe monitoring system control panel(console). Ifthere is no control panel(e.g,,only an electrical re ay box is installed)leave this space blank. 490-56. M DEL#- Enter the model number for the monitoring system control panel(console).If there is no control panel(e.g.,only an electrical relay box is installed)leave th' sp ce blank. 490-57, LE kK SENSOR MANUFACTURER—Enter the name ofthe manufacturer ofthe sensor(s). 490-58. M DEL#(S)—Enter the model number ofthe sensor(s)installed.If additional space is needed,use Section X. 490-59 DE rECTION OF A LEAK INTO THE UDC TRIGGERS AUDIBLE AND VISUAL ALARMS. Indicate Yes or No 49D-60, UE C LEAK ALARM TRIGGERS PUMP SHUTDOWN- Indicate Yes or No 490-61. FA LURE/DISCONNECTION OF UDC MONITORING SYSTEM TRIGGERS AUTOMATIC PUMP SHUTDOWN-Indicate Yes or No 490-62. MONITORING STOPS THE FLOW OF PRODUCT AT THE DISPENSER-Indicate Yes or No. 490-63, UDC CONSTRUCTION- Indicate if the construction of the UDC is single-walled,or double-walled. 490-64a.DC UBLE-WALLED INTERSTITIAL SPACE MONITORING- Indicate what is used to monitor the interstitial space. 490-65 LEkk 490-65. WITHIN THE SECONDARY CONTAIMENT OF UDC TRIGGERS AUDIBLE AND VISUAL ALARMS-Indicate Yes or No Vl I ELD TESTING-Check the box if you have been notified by the State Water Resources Control Board(S WRCB)that the UST(s)covered by this plan is/are sutject to Enhanced Leak Detection Requirements(i.e.,UST has any single-wall 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 ifyou have secondary containment that requires testing 490-67. SPILL BUCKET TESTING-Check the box ifyuu have spill buckets, 490-68a-h.VHI RECORDKEEPING-Indicate which monitoring and equipment maintenance records are maintained for this facility. 490`69a IX TRAINING STATEMENT-Check the box to verify that the statement is true. ERENCE DOCUMENTS MAINTAINED AT FACILITY—Check the appropriate boxes to describe reference documents maintained at the facility, Note that the f t 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. 490-69e. 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 RESOURCES 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,OT -Indicate that other reference documents are kept, 490-69i. SPE IFY-If"OTHER"is checked,enter a brief description ofthe other document(s)maintained at the facility.If additional space is needed,see Section X. 490-70. DES IGNATFD OPERATOR TRAINING-Check this box to verify that this statement is true. 490-71, CO NTS/ADDITIONAL INFORMATION—Make additional comments or you may attach and identify the number of additional pages of information to describe any ditionai UST system monitoring-related information(e.g.,additional information required by your local agency). Attach any monitoring logs that you will be using for tI a monitoring ofyour tank system. 490-72. N —Enter the name ofthe person who routinely conducts the monitoring and equipment maintenance under this plan. 490-73. TITL - Enter the title of the person. 490-74. N Enter the name of the second person,if applicable,who routinely conducts the monitoring and equipment maintenance under this plan. 490-75. TITL - Enter the title of the second person. OWNWOPERATOR 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. 490-76. REPRESENTING--Check the appropriate box to indicate whether the signer is the UST owner/operator,the UST facility owner/operator,or an auth ized representative of the owner. 490-77, DA —Enter the date the plan was signed. 490-78. APPI ICANT NAME—Print or type the name ofthe person signing the plan. 490-79. APPI(CANT TITLE—Enter the title ofthe person signing the plan, UPCF UST-I) 12/2007)414