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(dgenry Use mime:Only) Thihas s plan been rev{owed and Approved [IAppmvod With Con pion. h Local Agency Su sV -- Date Comment i m Special Oooditioac. 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 instmctions follows the data element numbers on the form.) 490-54a.MONITORING OF THE UNDER DISPENSER CONTAINMENT-Indicate the method used for UDC monitoring. 490.546.SPECIFY-If 99"Other"is checked,describe other method Wed. If VI-I-I,VI-1.2 or VI-1-3 or VI-1-99 is checked,complete 490.55 to 4%-64b, 490-55. PANEL MANUFACTURER-Enter the muse:of the manufactmer ofthe monitoring system control panel(console). If there ism control panel to g.,only an electrical relay box is installed)leave this specs blank. 490.56. MODEL 0- Enter the model number for the monitoring system control panel(console).If then is m control panel(og.,only an electrical relay box is immlled)leave this space blank. 490.57. LEAK SENSOR MANUFACTURER-Enter the tame of the manufacturer of the scaxmx). 490-58. MODEL a(S)-Ernst the model number of the sensor(s)iustalled.If additintW space is needed,use Seema X. 490-59, DETECTION OF A LEAK INTO THE UDC TRIGGERS AUDIBLE AND VISUAL ALARMS. Indiana Yes or No 490.60. UDC LEAK ALARM TRIGGERS PUMP SHUTDOWN- Indicate Yes or No 490.61. FAILUR&DISCONNECTION OF(IDC MONITORING SYSTEM TRIGGERS AUTOMATIC PUMP SHUTDOWN-Indicate Yes or Nn 490-62 UDC MONITORING STOPS THE FLOW OF PRODUCT AT THE DISPENSER-Indicate Yes or No. 49043. UDC CONSTRUCTION- Indicate if the construction ofthe UDC is single-wailed,or doublewalhxl 490.64a.DOUBLE-WALL®INTERSTITIAL SPACE MONITORING- Indicate what is used to monitor the interstitial space. 490.64b.LEAK WITHIN THE SECONDARY CONTAIMEN I OF UDC TRIGGERS AUDIBLE AND VISUAL ALARMS-Indicate Yes or No 49045. VII-1 ELD TESTING-Clack the box if you have been notified by the State Water Resources Control Board(SWRCB)that the UST(s)covered by this plan ivare subject to Enhanced Leak Detection Requirements(i.e.,UST has any singlo-wall component and is located within 1,000 feet of a public drinking water well). 490-66. TESTING OF SECONDARY CONTAINMENT COMPONENTS E VERY 36 MONTHS-Check the box if you have secondary containment that requires resting. 49067. SPILL BUCKET TESTING-Check the box if you have spill buckets. 4904ga-h.VIII 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. REFERENCE DOCUMENTS MAINTAINED AT FACILITY-Check the appropriate boxes to describe reference documents maintained at the facility. Note that tM first two items on the list unig be kept at the facility. 49669b. MONITORING PLAN:Indicate that this plan is kept as a mfereme document. 49n,69c. 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 refereme document. 49049e. CA UST LAW-Indicate that this is kept as a reference document. 49049f 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 u a refereme dac ar ern. 490-69h OTHER-Indicate that other refereme dmuments ace kept. 49049;. SPECIFY-If"OTHER"u chocked,rarer a brief description ofthe other documents)maintained at the facility.If additional space is needed,see Section X. 490.70. DESIGNATED OPERATOR TRAINING-Check this box to verify that this statement is true. 490-71. COMMENTS/ADDITIONAL INFORMATION-Make additional comments or you may attach and identify the number of additional pages of inforimmon In describe any additional UST system monitmmg-related information(eg.,additional information required by your local agency). Attach any monitoring logs that you will be using for the monitoring of your tank system 490-72. NAME-Enter the name ofthe person who mutimly contacts the monitoring and equipment maintenance order this plan. 490.73. TITLE- Enter the tide of the person. 490.74. NAME-Enter the mama ofthe second person if applicable,who routinely conducts ttse monitoring and equipment maintenance under this plan. 490.75. TITLE- Enter the tide ofthe second person. OWNER/OPERATOR SIGNATURE-The tank ower/opersan facility owner/opemror,or m outpoured representative of the owner shall sign in the space provided. This signature certifies that the sigmr believes that all information submitted is true,accurate,and complete,and that the training pmgrdm specified in Section IX has been implemented. 490-76. REPRESENTING-Check the appropriate box to indicate whether the sigmr is the UST owner/operator,the UST facility owner/.pasta,or an authonwd representative ofthe owner. 490-77. DATE-Enter the date the plan was signed. 490-711. APPLICANT NAME-Print or type the nem of the person signing the plan. 490-79. APPLICANT TITLE-Enter the title ofthe person signing the plan. UPCP UST-D(17J2007)4/4