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(Agency Use Only) Local Agency SignaThis plan has been ren ed u, Mwd ❑Approved With ConditionsComments or Special l Co Conditions: Date: _ IIS 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 note 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.) 490-54&MONITORING OF THE UNDER DISPENSER CONTAINMENT-Indicate the method used for UDC monitoring. 490-54b.SPECIFY-If 99"Other'is checkert describe other method used. If VI-1-1,VI-1-2 or VI-1-3 or VI-1-99 is checked,complete 490-55 to 490-64b. 490-55. PANEL MANUFACTURER—Enter the more ofthe manufacturer ofthe mounting system control panel(colonic). Ifthem is m control panel(e.g.,oNy m elecWcal relay burr is installed)leave this space blank. 490-56. MODEL#- Enter the model number for the monitoring system control panel(console).If them is an control panel(e.g.,only an electrical relay box is iremllcd)leave this space blanc. 4911 LEAK SENSOR MANUFACTURER—Enter the name ofthe manufacturer of the sensor(s). 490-58. MODEL#(S)—Enter the model number of roe sensor(s)installed.Ifaddith n d space is needed,use Section X 490.59. DETECTION OF A LEAK INTO THE UDC TRIGGERS AUDIBLE AND VISUAL ALARMS. Indicate Yes or No 490.60. UDC LEAK ALARM TRIGGERS PUMP SHUTDOWN-Indicate Yes or No 49061. FAILUREMISCONNECTION OF UDC MONITORING SYSTEM TRIGGERS AUTOMATIC PUMP SHUTDOWN-Indicate Yes or No 49062. UDC MONITORING STOPS THE FLOW OF PRODUCT AT THE DISPENSER-Indicate Yes or No. 49063. UDC CONSTRUCTION- Indicate ifthe construction ofthe UDC is single-walled,or doublo-walicd. 490-64a DOUBLE-WALLED 114TERSTITIAL SPACE MONITORING- Indicate wind is used to monitor the interstitial space. 490-64b.LEAK WITHIN THE SECONDARY CONTAIMENT OF UDC TRIGGERS AUDIBLE AND VISUAL ALARMS-Indicate Yes or No 49065. VII-I ELD TESTING-Check the box ifyou have been notified by the State Water Resources Control Board(SWRCB)that the UST(s)covered by this plan is/me subject to Enhanced Leak Detection Requirements(i.e.,UST bas any single-wall component and is located within 1,000 feet arm public drinking water well). 49066. TESTING OF SECONDARY CONTAINMENT COMPONENTS EVERY 36 MONTHS-Check the box ifyou have secondary conWnmeat that requires testing. 49067. SPILL BUCKET TESTING-Check the box ifyou have spill buckcts. 49068a-h.VIE RECORDKEEPING-Indicate which monitoring and equipment maintenance records are maintained for this facility. 49069a IX TRAINING STATEMENT-Check the box to verify that the statement is hue. REFERENCE DOCUMENTS MAINTAINED AT FACILITY—Check the appropriate boxes to describe reference documents maintained at the facility. Note that the fast two items on the list must be kept at the facility. 49069b. MONITORING PLAN:Indicate that this plan is kept as a reference document. 49069c. OPERATING MANUALS FOR ELECTRONIC EQUIPMENT:Indicate that this plat is kept as areference docunsent. 490-69(. CA USE REGULATIONS-Indicate that this is kept as a reference document. 49069e. CA UST LAW-Indicate that this is kept as a reference document. 49069f 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 490691.OTHER-Indicate that other reference documents are kept. 49069L SPECIFY-H"OTHER"is checked,enter a briefdescription ofthe other documents)maintained at the facility.Ifadditional space is needed,see Section X. 490.70. DESIGNATED OPERATOILTRAINING-Check this box to verify that this statement is hue. 490-71. COMMENTS/ADDITIONAL INFORMATION—Make additional comments or you may attach and identify the number of additions pages of information to describe any additional UST system monitoring-related inflammation(e.g.,additional information required by your local agency). Attach any monitoring logs that you will be using for the monitoring ofyour rank system. 490-72. NAME—Enter the nuns ofthe person who routinely conducts the monitoring and equipment maintenance under this plan. 490-73. TITLE- Enter the title ofthe person. 490.74. NAME—Enter the name of the second person,ifepplicable,who routinely conducts the monitoring and equipment maintenance under this plan. 490-75. TIME- Enter the tide ofthe second person. OWNER/OPERATOR SIGNATURE—Tie tank ovnedopemtor,facility owner/operator,or an annulling representative ofthe owner shall sign in the space provided. This signature certifies that the signer believes that all information submitted is hue,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 USE facility owner/opemlo,or an authorized representative of the owner. 490-77. DATE—Enter the date tie plat was signed. 490-78. APPLICANT NAME—Print or type the name ofthe person signing the plan. 490-79. APPLICANT TITLE—Enter the title ofthe person signing the plan. UPCF UST-D(12/2007)4/4