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(Agency Use Only) This plan has b eviewed a d' Appro ed ❑Approved With Conditions ❑Disapproved Local Agency Signature: Dale: --y�� Comments or Special Conditions: UPCF UST Monitoring Plan— Page 2 Instructions ------------------------------------------------------------------------------------------------------------------------------------------------ VLUDC MONITORING—Check the appropriate box(es)to describe monitoring of DOC systems covered by this plan. 490-54a. UDC MONITORING METHOD(S)—Check the appropriate box(es)to identify all required methods used for monitoring the area(s)beneath the dispenser(s). Check item 490-54a-1 if the UDC is monitored by a leak sensor connected to a continuous monitoring console with audible and visual alarms. Check item 490-54a-2 if the UDC is monitored by a mechanical device that shuts the dispenser's shear valve when liquid in the UDC lifts a leak detection Float.Check item 490-54a-3 if the UDC is monitored by a stand-alone leak sensor that is not connected to a continuous monitoring console.If no dispensers are installed (e.g.,emergency generator tank system),check item 490-54a-4 and skip to Section VB. Check item 490-54a-5 if the UDC is monitored by other methods. 490.54b. SPECIFY—If item 490-54a-99 is checked,enter a brief description of the other UDC monitoring method(s)used. If more space is needed,use Section X. Be sure to clearly describe monitoring method(s)and frequency. 490-55. LEAK MONITOR MANUFACTURER—If item 490-54a-t is checked,enter the name of the manufacturer of the monitoring system control panel(console). 490-56. MODEL#—If item 490-54a-1 is checked,enter the model number for the monitoring system control panel. 490.57. LEAK SENSOR MANUFACTURER—If item 490-54a-1 or 490-54a-3 is checked,enter the time of the manufacturer of the sensor(s).,If mom space is needed,use Section X. 490-58. MODEL d(S)—If item 490-54a-1 or 490-54a-3 is checked,enter the model number for each type of sensor installed.If mom space is needed,use Section X. 490-59. WILL DETECTION OF A LEAK INTO THE UDC TRIGGER AUDIBLE AND VISUAL ALARMS?—Check Yes or No. 490-60. WILL UDC LEAK ALARM TRIGGER PUMP SHUTDOWN?—Check Yes or No. 490.61. WILL FAILUREIDISCONNECTION OF UDC MONITORING SYSTEM TRIGGER SHUTDOWN?—Check Yes or No. 49062. WILL UDC MONITORING EQUIPMENT STOP THE FLOW OF PRODUCT AT THE DISPENSER UPON LEAK DETECTION?—Check Yes or No. 49063. UDC CONSTRUCTION—Check the appropriate box to indicate whether the UDC has single wall or double wall construction.if you check item 490-63-1, skip to Section VII. 49064a.UX; INTERSTITIAL SPACE IS—If you check item 49063-2,check the appropriate box to describe the type of vacuum/pressure/hydrostatic(VPH) monitoring provided for the UDC secondary containment. 490-64b.WILL DETECTION OF A LEAK IN THE UDC INTERSTITIAL SPACE TRIGGER AUDIBLE AND VISUAL ALARMS?—If you check item 490-63-2, _________check Yes or No. SYSIENES &d 490-65. VH.PERIODIC SYSTEM TESTING 490-65. ELD TESTING—Check this box if the SWRCB has notified you that you must perforneo riodic Enhanced Leak Detection(ELD).You do not need to check this box if you need to perform one-time ELD testing(e.g.,post-installation testing) 490-66. SECONDARY CONTAINMENT TESTING—You must check this box and provide periodic testing if you have any UST system secondary containment components that are not exempt from testing because they am monitored by a continuous vacuum/pressure/hydrostatic monitoring system. _490-67,_ SPILL BUCKET TESTING-You must check this box and provide annual testing,of all UST f II spill buckets------------------------------------ VEIL- -------------- VIII.RECORD KEEPING - - ---- _490_68__MONITORINGIMAINTENANCE RECORDS_Check the appropriate bones m indicate UST records kept for the facility. _ ix.TRAINING 490.69. Check the box for item 490-69a to indicate that personnel with UST monitoring responsibilities are familiar with relevant reference documents.Check the appropriate boxes for items 490-69b through h to identify reference documents that are maintained at the facility. Note that items 490-69b and c am mandatory. 490-691. SPECIFY—If item 490-69h is checked,enter a brief description of the other reference documents maintained at the facility. 490-70. DESIGNATED UST OPERATOR—You must check this box and have at least one Designated UST Operator currently certified by ICC.Your Designated UST Opemtor(s)must perform and document monthly visual inspections of UST system components and provide required initial and annual refresher training for facility,personnel. _ X.COMMENTS/ADDITIONAL INFORMATION 490-71. You may use this section to describe any additional UST system monitoring-related information(e.g.,additional information required by your local agency). If using Section X as additional space for items required elsewhere in this plan,reference the item number(e.g.,"Item 490-33-Model 2468 and 3579 Leak Sensors"). XI.PERSONNEL RESPONSIBILITIES 490-72. NAME—Enter the name of the person with ultimate authority for performing the monitoring activities and maintaining leak detection equipment covered by this plan.If mom than one person has such authority,complete Item 490-74, 490.73. TITLE—Enter the title of the person with ultimate authority for performing the monitoring activities and maintaining leak detection equipment covered by this plan.If more than one person has such authority,complete Item 490-75.R not,skip to Section XII. 490-74. NAME—See instructions for item 490-72.If more than two people have such authority,note the additional names in Section X. 490.75. TITLE—See instructions for Item 490-73.If more than two people have such authority,note the additional names in Section X. _ ____ _ _ _ __ _ __________ -___.__ ___-_ _.__--_ XH.OWNER/OPERATOR SIGNATURE The owner/operator 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. 490-76. REPRESENTING—Check the appropriate box to indicate whether the signer is the UST owner/operator, the facility owner/operator, or an authorized representative of the UST owner. 490-77. DATE—Enter 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 tide of the non signing the plan. UPCF UST-D(121200')-414 www.unldocs.org Effective 01/17/08