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001201 (Agenry Use Only) This plan ❑Approved With Conditions ❑Disappro ed Local Agency Signature: �i f]�V nate: IfComments ar Special Condhi UPCF 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 mitral 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 approvalrD for to installing or modifying monitoring equipment. (Note. Numbering of these mstro tions follows the data element numbers on the form.) 490-54a MONITORING OF THE UNDER DISPENSER CONTAINMENT-Indicate the method used for UDC monitoring. 490-54b.SPECIFY-If99"Oiler"is checked,describe other method used. If VI-1-1,VI-1.2 or VI.1.3 or VI-I.99 is checked,complete 490.55 to 490-64b. 490-55. PANEL MANUFACTURER-Enter the come of the manuf'acturerofthe monitoring system control panel(console). Ifthere is no control panel(e.g.,only an electrical relay box is installed)leave this space blank 490-56. MODEL N-Enter the model number for the monitoring system control panel(wmole).If there is an control panel(e.g.,omy an electrical relay box is installed)leave this space blank. 490.57. LEAK SENSOR MANUFACTURER-Enter the name ofthe reanufacuter of the semor(s). 490-58. MODEL N(S)-Enter the model number ofthe amounts)installed.Ifadditional 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 POW SHUTDOWN-Indicate Yes or No. 490.61. FAILURE/DISCONNECTION OF UDC MONITORING SYSTEM TRIGGERS AUTOMATIC PUMP SHUTDOWN-Indicate Ya mNo. 490-62. UDC 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-welled,or double-walled. 490.648.DOUBLE-WALLED]INTERSTITIAL SPACE MONITORING-Indicate what is used to monitor the interstitial space. 496-646.LEAK WITHIN THE SECONDARY CONTAINMENT OF UDC TRIGGERS AUDIBLE AND VISUAL ALARMS-Indicate Yew or No. 490-65. VII-I BLD TESTING Check the box if you have been notified by the State Water Resources Control Board(SWRCB)Flat the UST(s)covered by this plan rstare subject to Enhanced Leak Distinction Requirements(i.e.,UST has any singlawall component and is located within 1,000 feet ofe public drinking water well). 490.66. TESTING OF SECONDARY CONTAINMENT COMPONENTS EVERY 36 MONTHS-Check the box ifyou have secondary containment that requirestesting. 496-67, SPILL BUCKET TESTING-Check the box ifyou have spill buckets. 490-68. VDI RECORDKEEPING-Indicate which monitoring and equipment maintenance records are maintained for this facility. 490.69& LXTRAINNG STATEMENT Check the box to verify,that the stmement is tree. REFERENCE DOCUMENTS MAINTAINED AT FACILITY-Check the appropriate,boxes to describe reference documents maintained at the facility. Note that the first two items on the list must be kept in the facility. 490-69b.MONITORING PLAN:Indicate that this plan is kept as a reference document. 49069c.OPERATING MANUALS FOR ELECTRONIC EQUIPMENT Indicate that this plan is kept as a reference document. 496.694 CA UST REGULATIONS-Indicate that this is kept as a reference document. 490-690.CA UST LAW-Indicate that this Is kept in a reference document. 490.69E STATE WATER RESOURCES CONTROL BOARD(S WRCB)PUBLICATION "HANDBOOK FOR TANK OWNERS-MANUAL AND STATISTICAL INVENTORY RECONCILIATION Indicate that this is kept as a reference document. 490.698.SWRCB PUBLICATION "UNDERSTANDING AUTOMATIC TANK GAUGING SYSTEMS Indicate that this is kept as a reference document. 490-69h.OTHER- Indicate that other reference documents are kept. 490-69i. SPECIFY If")TIER"is checked,ender abriefdeseription ofthe other documents)maintained m the facility.Ifadditional space is needed,see Section X. 49070. DESIGNATED OPERATOR TRAINING-Check this box to verify,that this statement is true. 49071. COMMENTS/ADDITIONAL INFORMATION-Make additional comnrcma or you may abash and Identify the number of additional pages of information to describe any additional UST system monitoring-related information(e.g,additional infomertion required by your local agency). Attach any monitoring logs that you will be wing for the monitoring ofyour tank system 490.72. NAME-Enter the come ofthe person who routinely conducts the monitoring and equipment maintenance under this plan. 49073. TITLE-Enter the title of the person 4911-74. NAME-Enter the woe ofthe second person,ifteppliwble,who routinely conducts the monitoring and equipment maintenance under this plan. 490.75. TITLE-Enter the tide of the second person. OWNEWOPERATOR SIGNATURE-The tank owner/operator,facility owcer/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 49076. REPRESENTING Check the appropriate box to indicate whether the signer is the USI owner/operator,the UST facility owner/opamtor, or an authorized ropaesenmtive ofthe owner. 49077. DATE-Enter the date the plan was signed. 49078. APPLICANT NAME-Prim or type the come of the person signing the plan. 49079. APPLICANT TITLE-Enter the title ofthe person signing the plan. UPCF UST-D(1212007) 4/4 www.uolducsArg