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(Agency Use Only) This plany7haas been re.mwged�s id: ❑Approved ❑Approved With Condifions Local Agency Siguahoe: rY �'/cryI^ Data: Comments or Special Conditions: 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.) 490-54a.MONITORING OF THE UNDER DISPENSER CONTAINMENT-Indicate the method used for UDC monitoring. 490-54b.SPECIFY-If 99"Other"is checked,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 name ofthe manufacturer ofthe monitoring system control panel(console). If there is no control panel(e.g..only at electrical relay box is installed)leave this space blank. 490-56. MODEL#- 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 this space blank. 490-57. LEAK SENSOR MANUFACTURER—Enter the name of the manufacturer ofthe semsor(s). 490.58. MODEL#(S)—Emer the model number ofthe sensors)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 PUMP SHUTDOWN- Indicate Yes or No 490-61. FAILURE/DISCONNECTION OF UDC MONITORING SYSTEM TRIGGERS AUTOMATIC PUMP SHUTDOWN-Indicate Yes or No 490.62. UDC MONITORING STOPS TEE FLOW OF PRODUCT AT THE DISPENSER-Indicate Yes or No. 490-63. UDC CONSTRUCTION- Indicate ifthe wet fion ofthe UDC is singlo-walled,or double-walled. 490-64a DOUBLE-WALLED INTERSTITIAL SPACE MONITORING- Indicate what is used to monitor the imemlifial space. 490-64b.LEAK WITHIN TIE SECONDARY CONTAIMENI OF UDC TRIGGERS AUDIBLE AND VISUAL ALARMS-Indicate Yes or No 490-65. VU-1 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 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 ifyou have spill buckets. 490-68a-h.VIE 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 We. REFERENCE DOCUMENTS MAINTAINED AT FACILITY—Check the appropriate boxes to describe reference documents maintained at the facility. Note thin the fust two items on the list most be kept at the facility. 490.696. MONITORING PLAN:Indicate that this plan is kept as a reference document. 490.69c. OPERATING MANUALS FOR ELECTRONIC EQUIPMENT:Indicate that this plan is kept 0 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 0 a reference document. 490-69g.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"OTIIFRII is checked,enter a briefdescription of the 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 oryou may match and identify the number ofadditional pages of information to describe any additional UST system monitoring-related information(e.g.,additional information required by your local agency). Attach any monitoring logs that you will be using for the monitoring ofyour book system. 490.72. NAME—Enter the name 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 more ofthe second persoq if applicable,who rominely conducts the monitoring and equipment maintenance under this plan. 490-75. TITLE- Enter the tide ofthe second person. OWNER/OPERATOR SIGNATURE—The tank owner/operator,facility owner/operator,or an authorized representative of the owner shell sign in the space provided. This signal=cenifies that the signer believes that all information submitted is true,accurate,and complete,and that the training program specified in Section DX has been implemented. 490-76. REPRESENTING—Check the appropriate box to indicate whether the signer is the UST ownet/operator,the UST facility owner/operator,or an authorized representative ofthe owner. 490-77. DATE—Ewer the date the plan was signed. 490.78. APPLICANT NAME—Prim or type the name of the person signing the plan 490-79. APPLICANT TITLE—Enter the title ofthe person signing the plan. UPCF UST-D(12/2007)4/4