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(Agency.Use Only) This plan has been revitApe!and. 'W Approved ❑Approved With Condlp4 E Local Agency Signal=: 6I • �/9-/%ye-, Date: - 10(S r f Comments or Special Conditions: —r 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 CUNI'AINMENf-Indicate the method used for UDC momtonng. 490-54b.SPECIFY-if 99-Other"is checked,describe other method used. If VI-1-1,VI-t-2 or VI-1-3 or VI-1-99 is checked,complete 490.55 to 490-64b. 490.55. PANEL MANUFACTURER-Enter the name of the manufacturer of the monitoring system control panel(console). If there is an control panel(e.g.,only an electrical relay box is installed)leave this space blank. 490-56. MODEL#- Enter the model number for the monitoring system cannot panel(console).If there is no control panel(eg,only an electrical relay box is installed)leave this space blank. 490.57. LEAK SENSOR MANUFACTURER-Enter the name of the manufacturer of the sensor(s). 490-58. MODEL#(S)-Enter the model number of the sensor(s)installed If additional space is needed,use Section X. 490-59. DETECTION OF A LEAK INTO THE UDC TRIGGERS AUDIBLE AND VISUAL ALARMS, Indicate Yes m No 490-W t1DC LEAK ALARM TRIGGERS PUMP SHUTDOWN- indicate Yes or No 490-61. FAILURE(DISCONNECITON OF UDC MONITORING SYSTEM TRIGGERS AUTOMATIC PUMP SHUTDOWN-Indicate Yes or No 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-walled,or double-walled. 490b1a DOUBLE-WALLED INTERSTITIAL SPACE MONITORING- Indicate what 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 490-65. VII-1 ELD TFSTING-Check the box if you have been notified by the State Water Resources Control Board(SWRCB)that the UST(s)covered by this plan is/are subject to Enhanced Leak Detection Requirements(i.e.,UST hes 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 if you have secondary containment that requires testing. ` 490-67. SPILL BUCKET'TESTING-Check the box if you have spill buckets. 490-68a-h.VIR RECORDKEEPING-Indicate which monitoring and equipment maintenance records are maintained for this facility. 490.69s IX TRAINING STATEMENT-Check the box in verify that the statement is true_ REFERENCE DOCUMENTS MAINTAINED Al FACILITY-Check the appropriate boxes to describe reference documents maintained at the facility. Now that 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 as a reference document 490-69111 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-W..STATE WATER RESOURCES CONTROL BOARD(SW RCB)PUBLICATION- "HANDBOOK FOR TANK OWNERS-MANUAL AND STATISTICAL INVENTORY RECONCILIATION-Indicate that this is kept as a odanrmce document 490-69g.SWRCB PUBLICATION:`UNDERSTANDING AUTOMATIC TANK GAUGING SYSTEMS":Indicate that this is kept m a reference document. 490-69h_OTHER-Indicate that other reference documents are kept. 490-691. SPECIFY-If"OTHER"is checked,enter a brief description of the other documen(s)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 information w describe any additional UST system moultaring-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 of the person who routinely conducts the monitoring and equipment maintenance under this plan. 490.73. TITLE- Enter the title of the person 490.74. NAME-Enter the name of the second person,if applicable,who routinely conducts the monitoring and equipment maintenance under this plan. 490-75. TITLE- Enter the tide of the second person. OWNER/OPERATOR SIGNATURE-The tank owner/operator,facility owner/operator,or an traditional representative of the owner shall sign in the space provided This signature certifies that the signer believes that all information submitted is toe,accurate,and complete,and that the training program specified in Section IS has been implemented. 490-76. REPRESENT ING--Check the appropriate hos to indicate whether the signer is the UST owner/operator,the UST facility owner/operator,or an authorized representative of the owner. 490-77. DATE-Enter the daze the plan was signed 490-78. APPLICANT NAME-Print or type the name of the person signing the plan. 490-79. APPLICANT TITLE-Enter the title of the person signing the plan. UPCF UST-D(122007)4/4