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UPCF UST Monitoring Plan-Page 1 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. Your local agency may require you to obtain approval El;Lo tc installing or modifying monitoring equipment__{Note__Numbering of these instructions follows the data element numbers on the form.. 490-1. TYPE OF ACTION-Check the appropriate box to indicate why this plan is being submitted. 490-2. PLAN TYPE-Check the appropriate box to indicate whether this plan covers all,or only some,of the USTs at the facility. 490-2a. If item 490-2-2 is checked use the space provided to identify the tanks covered by this plan [e.g.,by using the Tank ID#(s)in hem 432 of the Unified P _________ rogram Consolidated Form(UPCF)UST Operating Permit Application_Tank Information Form(s)J------------------------------------------------ L FACILITY INFORMATION I. FACILITY ID NUMBER-This space is for agency use only. 3. BUSINESS NAME-Enter the complete Facility Name. 103. BUSINESS SITE ADDRESS-Enter the street address where the facility is located,including building number,if applicable.Post office box numbers are not acceptable. This information must provide a means to locate the facility geographically. 104.____BUSINESS SITE CITY-Enter the city or unincorporated ata in which the facility is located, H.EQUIPMENT TESTING AND PREVENTIVE MAINTENANCE 490-3a. MONITORING EQUIPMENT IS SERVICED-Check the appropriate box to specify the frequency of monitoring equipment testing/cenifrcation. 490-3b. SPECIFY_Specify Other frequency of monitoring equipment testing/certification. _ __......__-...___.----------------------------------.-.----.--_-_____. III.MONITORING LOCATIONS 490-4. SITE PLOT PLAN/MAP-Check the appropriate box to specify whether Site Plot Plar✓Map is attached or was previously submitted.UST Monitoring Plans must include a Site Plot Plan/Map showing the tank and piping layouts and the locations where the monitoring is performed(i.e.,location of sensors,probes, _________ line leak detectors_monitoringsy_stemcontrolp_anehetc.2._ _x(es)t__-___-____equire-m-_---uses-omon..r-._--. cover_ bythis___________________ rv.TANK MONITORING METHOD(S)-Check the appropriate box(es)to identify all required methods used to monitor UST(s)covered by this plan. 490-5. CONTINUOUS ELECTRONIC MONITORING-Check this box if tank secondary containment is continuously monitored. 490-6. SECONDARY CONTAINMENT IS-Check the appropriate box to describe the environment inside tank secondary containment. 490-7. PANEL MANUFACTURER-If item 490-5 is checked,enter the name of the manufacturer of the monitoring system control panel(console). 490-8. MODEL#-Enter the model number for the monitoring system control panel. 490-9. LEAK SENSOR MANUFACTURER-Enter the name of the manufacturer of the semor(s).If more space is needed,use Section X. 490-10. MODEL#(S)-Enter the model number for each type of sensor installed.If more space is needed,use Section X. 490-11. AUTOMATIC TANK GAUGING-Check this box if single-wall tanks are monitored by an ATG system. 490-12. PANEL MANUFACTURER-Enter the name of the manufacturer of the ATG system control panel(console). 490-13. MODEL#-Enter the model number for the ATG system control panel. 490-14. IN-TANK PROBE MANUFACTURER-Enter the name of the manufacturer of the probe(s). 490-15. MODEL#(S)-Enter the model number for each type of in-tank probe installed.If more space is needed,use Section X. 490-16. LEAK TEST FREQUENCY-Check the appropriate box to describe the in-tank leak test frequency. 490-17. SPECIFY-Enter the frequency of programmed leak tests. 490-I8. PROGRAMMED TESTS-Check the appropriate box to describe the tests programmed into the ATG system. 490-19. SPECIFY-Enter the Other frequency of in-tank leak testing. 490-20. STATISTICAL INVENTORY RECONCILIATION(SIR)-Check this box if single-wall tanks are monitored using SIR. 490-21. MANUAL TANK GAUGING(MTG)-Check this box if single-wall tanks are monitored using MTG. 490-22. TESTING PERIOD-If item 490-21 is checked,check the appropriate box to describe the MTG testing period. 490-23. TANK INTEGRITY TESTING-Check this box if single-wall tanks are monitored using integrity tests performed by a State-licensed tank tester. 490-24. TEST FREQUENCY-If item 490-23 is checked,check the appropriate box to describe the frequency of tank integrity testing. 490-25. SPECIFY-Enter the Other frequency of tank integrity testing. 490-26. OTHER-Check this box if the tanks are monitoring using methods other than those listed above. 490-27. SPECIFY-If item 490-26 is checked,enter a brief description of the other tank monitoring method(s)used(e.g,Vadose Zone Monitoring per 23 CCR ___ _ . t!2647,Groundwater Monitoring per 23 CCR§26482. Include the monitoring frequency(eg._continuous:weeklY).If more space ri neededi use Section X. _____ __._.._ _______ dent-_ V.PIPE MONITORING METHOD(S)-Check the appropriate box(es)to identify all required methods used to monitor UST piping systems covered by this plan. 490-28. CONTINUOUS MONITORING-Check this box if piping secondary containment is continuously monitored. 490-29. SECONDARY CONTAINMENT IS-Check the appropriate box to describe the environment inside piping secondary containment. 490-30. PANEL MANUFACTURER-If item 490-28 is checked,enter the time of the manufacturer of the monitoring system control panel(console). 490-31. MODEL#-Enter the model number for the monitoring system control panel. 490-32. LEAK SENSOR MANUFACTURER-Enter the name of the manufacturer of the sensor(s). 490-33. MODEL#(S)-Enter the model number for each type of sensor installed.If more space is needed,use Section X. 490-34. PIPING LEAK ALARM TRIGGERS PUMP SHUTDOWN-Check Yes or No. 490-35. FAILURE/DISCONNECTION OF MONITORING SYSTEM TRIGGERS PUMP SHUTDOWN-Check Yes or No. 490-36. MECHANICAL LINE LEAK DETECTORS(MELD)-Check this box if MLLDs are used to monitor pressurized piping systems. 49037. MLLD MANUFACTURER(S)-If item 490-36 is checked,enter the name(s)of the manufacturer(s)of the mechanical line leak detector(s).If more space is needed,use Section X. 490-38. MODEL#(s)-Enter the model number for each type of mechanical line leak detector installed.If more space is needed,use Section X. 490-39. ELECTRONIC LINE LEAK DETECTORS(ELLD)-Check this box if ELLDs are used to monitor pressurized piping systems. 490-40. ELLD MANUFACTURER-If item 490-39 is checked,enter the time of the manufacturer of the electronic line leak detector(s). 490-41. MODEL#(S)-Enter the model number for each type of electronic line leak detector installed.If more space is needed,use Section X. 490-42. PROGRAMMED IN-LINE LEAK TEST-Check the appropriate box to describe the type of tests programmed into the monitoring system. 49043. ELLD DETECTION OF A PIPING LEAK ALARM TRIGGERS PUMP SHUTDOWN-Check Yes or No. 490-44. ELLD FAILURE/DISCONNECTION TRIGGERS PUMP SHUTDOWN-Check Yes or No. 49045. PIPE INTEGRITY TESTING-Check this box if piping systems are monitored using integrity tests performed by a State-licensed tank tester. 49046. TEST FREQUENCY-If item 490-45 is checked,check the appropriate box to describe the frequency of pipe integrity testing. 49047. SPECIFY-If item 490-46-c is checked,enter the frequency of pipe integrity testing. 49048. VISUAL PIPE MONITORING-Check this box if piping systems are visually monitored. 49049. FREQUENCY-If item 490-48 is checked,check the appropriate box to describe the frequency of visual monitoring. 49050. SUCTION PIPING MEETS EXEMPTION CRITERIA-Check this box if piping meets all requirements of 23 CCR§2636(a)(3). 49051. NO REGULATED PIPING-Check this box if there is no regulated piping connected to the tank(s)covered by this plan. 49052. OTHER-Check this box if the piping is monitoring using methods other than those listed above. 49053. SPECIFY-If item 49052 is checked,enter a brief description of the other line monitoring method(s)used. If more space is needed,use Section X. Be sure to clearly describe monitoring methods)and frequency. UPCF UST-D(12/2007)-2/4 www.unldocs.org Effective 01/17/08