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(Agency(Ise Only) 'Phis plan has boon reviewed and: 151lAppmswd ❑Approved With Conditions ❑Disapproved <br /> Local Agency Signature:_ M �"ti�^' - Dale: <br /> Comments or Special Conditions: <br /> UPCF UST Monitoring Plan -Page 2 Instructions <br /> Complete a sepatate UST Monitoring Plan for each UST monitoring system at the facility, This form must he submitted with your initial UST <br /> Operating Permit Application and within 30 days of changes in the information it contains. Please note that your local agency may require you to <br /> obtain approval Rjj2r to installing or modifying monitoring equipment. (Note: Numbering of these instructions follows the data clement numbers on <br /> the fnnn.) <br /> 490-. n. MONITORING OF THF:UNDER DISPENSER CON'rAINMI.NT-Indicate Elio methodused for UDCmoniloring. <br /> 490.546.SPECIFY--11`99"Other•'is checked,describe other nothod used. <br /> i(VI-1-I,VI-1-2 ar VI-1.3 or VI-I-99 is checked,complMc 490-55 to 490.64b. <br /> 490-55. PANEI.SIANUFACTUItER Enter the nanwoft6e nannfacutreruftbe nwnit,rcing system convol panel(<asnle). IfNerc mno wnlrol pancl(e.g.,only an cimrical <br /> relay box is installed)lia ve this space blank. <br /> 490-56. MODEL.P-inter Ibc model number for Nc monitoring system control panni(console).If Nmc is no cmntnl panel(e.g.,only an cfactiical relay box is installed)Ic m <br /> this spax,blank. <br /> 490-57. IA:AK SENSOR MANUFAcTuRi:R- 17ncr the nom of the mavt,fuulnmr of the scnsor(s). <br /> 490-5R. MODE1.1i Izncrthe ntadd naulrcrofdnsensm(s)installed lfaddi[iunnlspaceis needed,ow Section X. <br /> 490-59. Dl.TECTIONO1'ALE:AKINTO'T'1113UDC'ritIGGEItSAU0i0LEANDVISIIALAI..ARMS. Indicval'csur No. <br /> 4901-60. 11DC LI,'AK ALARM'IRIOC.EIiS PUh91'SIIUTDOWN-Inxlieatn Yes or No. <br /> 490-61. FAILURl9DISCONNFcTiON OP UDC MONI'T'ORING SYS TTSM TRIGGERS AUTOMATIC PUMP SI RM)OWN -htdknte Yesor No. <br /> 490-62. UDC MONri,oitING STOPS TIII:Iq..OW 01'PRODUC'I'A'fTIIE DISPENSER-Indicmc l'cs or No. <br /> 490-63. UDCCONSCKLicrIDN-Tndicaleifuucoaam:dinnorthc UDCissinglo-srdied.oidmtblownlled. <br /> 490-64a, DOUI31.i'i-\VALLI3D INTIiItSTITIAL SI+ACIP MONITORING-Indintc who is ascd m moniart the itdcrsiilinl space, <br /> 490-64b.LEAK W RIiIN'I'I HE SECONDARY CONTAINMENT OP UDC TRIGGERS AUDIBLE AND VISUAL ALARMS-Indicate Yesor No. <br /> 4911-65. VII-I ELD TES'HNG- Check the box if you have been notified by the Stale Water Resources Control Board(SWR(IG)Thal the UST(s)en¢md by this plan is/arc <br /> subject m Enhanced Leak Detection Requirements Go,LIST has any single-wall component and is located within 1,000 feel oft,public drinking sumer well). <br /> 490-66. 'TrS'I'INC.OP SECONDARY CONTAINMENT COMPONENTS EVIiRY 36 MONTUS-Cheeklin box ifyou bavc secondary containment fill[regoims testing. <br /> 490-67. SPILL.BUCKETTESTINE -Check the box ifyou have spill bockds. <br /> 490-68. VIII RL•CORDKIiIiI'M(i-bklicawr6ieh monitoring,Ed eyuipmemmaimurance records anarmintained lar this facility. <br /> 490-69a, ixTRA1NINCST'ATEMENT C'beckthe boxwrerify Elim[ho sataucm ix ran. <br /> RIiFERi!NOE DOCIIMENTS h4A1NTAINI!D A"I'FACIA-I"I'Y-.(I eek the appuopdnac limits In dcecribe rcrereme doennents nainuincd a[Nc facility. Nolo that the <br /> ftml nm items on the list mag be kept a1 the fsility. <br /> 490-691). MONITORING PLAN:Indicate thin this plan is kept us a telcistwe dol,tal 1. <br /> 490.69c.OPERATING MANUALS FOR ELECTRONIC EQIIIPMI:N r:Indicate that tins plan is kept asn rcl'arenee dm:utnenl. <br /> 490.69(1.CA LIST REGULATIONS-In<lican Ihnt this is kcpu as a rcfentwc ducnmcnt. <br /> 490-69c. G\UST V\W_Indicate Nal This is kept as a rcferetwe<locunnnl. <br /> 490.6917, STl A IF WATER RFSOURCPS CONTROL ROAIlD(SWRCR)PURIACATION - '•IIANDI30OK FOR TANK OWNERS-MANILAL AND <br /> ST'A-I'ISTICAL INV ENT'ORY RECONCILIATION":Indic.that Nis is kept as a mfcm-lw dncumant. <br /> 490.69g.SW RCI)PUBLICATION:"UNDERS9'ANDINCi AU'FOMATIC'fANK GAU(iING SYSTEMS:Indicalc that this is kept as a refe,mm document. <br /> 490.6911.OTHER- Otdicac Nal mhcr mfcrctwc doanncnts arc Imps. <br /> 490-69i. SPECIIY-If^OT'I llili"is r6ccked,mdcrn briefdescripfion of tfic nthcrdaunxknl(s)nvnimained;n Ne fxilily'.IGxklitimral space ixnr_•daL see Section X. <br /> 490-70. DESIONA"II.DOPEBA•I'OR'I'RAINfNCi-Ciwck tbiz lxtx to vtxilp[hal this slakmnnl is frac. <br /> 490-7I. COMkiIiN'1'Si:\DUI"I'IONAI.INFORMA'T'ION Makeaddiiional rnmmenlsor yml mayntomhand identify tin number o(addivaral pagesof imiantntie+todescribe <br /> any ad,minind usT system mnniwrinp-roltaal information(cg..additimtnl i:dormntion required by your Imvl agency). Alraeh any morn n ring loss that you avid he <br /> tuna,I'o'nic nwnimring of yawr lank system <br /> 490.72. NA\Ili-dinar the n:enc of the person who rmnincly a ducts the monitoring and mpipnwnt maimelnnce under his pian. <br /> 490-73. Til"I,F P.nterthctidcof Nclursna. <br /> 490.74. NA&Ili -Enter the na:mof the second pcmon.ifapplieahk.I,ho..... dycatdndslhe mwitoring:utA ttpnilanenl mainlenmac under Ibis pfiut. <br /> 490-75. TTI'Llt-L.lac,the Idle n rdicsecond pennant. <br /> OWNEIUOPER.4T'OR SIGNA'I URti--The tank ownednpemtur,facility nwnedopealor.or an anlwrtzed repxestani(vc of the owner shall sign in Ibc space provided. <br /> This signature certifies that the signer b Beres that;dl information suhinivet is[me.avcnrau,EEnd complete,and Nm the Imining program spaifted in'ediou IX las <br /> been haplemenlcd. <br /> 490-76. RIi IRBENI'INO - Check Ehc appropriate box to indicate whedAY Ila idignelIs the list'owncilnlernar, Ibc UST facility of woopcmbr, or at uuthori2ed <br /> represcnallm 01 the owner. <br /> 490-77. DA'rli...1_Iltd'the dole the plan was sigced. <br /> 490-78. APPIAC'ANI'NAME. Print or lylic Nc mannfthc pcnonsigtting On pian. <br /> 490_79. APPLICAN"r"FITLF.- F.ntcr ulie titicof the pctsmtsigning the plan. <br /> tHICF IN-r-D(1212007)-414 a vavwaoldoes.org <br />