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Na'(Agency Use On/y) This plan has been review-. and:pproved [I Approved With Condit - Local Agency Signature:Date: Comments or Special Con ns: UST Monitoring Plan — Page 2 Instructions a •;;•fir:; ....ch UST monitoring system at the facility. This form must be submitted with your initial UST in the information it contains. Please note that your local agency may require you to aWAU.al AjUL io Libialling 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 meths. ! •L!t-t4. If VI -1-1, VI -1-2 or VI -1-3 or Vi -1-99 is checked, complete 490-55 to 490-64b. -M ACTURER -Enter the name of the manufacturer of the monitoring system control panel (console). If there is no control panel (e.g., only an electrical leave this space blank. ;90-56. '..OI)& # - 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 of the sensor(s). 490-58. MODEL #(S) -Enter the model number of the sensor(s) install- 490-59. DETECTION OF A LEAK INTO THE UDC TRIGGERS AUDLRI F ,e _ n Vicr re m Al A v►.c r^a:,..,+., v p -NL. 490-60. UDC LEAK ALARM TRIGGERS PUMP SHUTDOWN =- ON OF UDC MONITORING SYSTEM TRIGGERS AUTOMATIC PUMP SHUTDOWN- Indicate Yes or No " :^=IE FLOW OF PRODUCT AT THE DISPENSER - Indicate Yes or No. :_=--uction of the UDC is single -walled, or double -walled •^^ • - • ^ •'• • • • ^^ NTTORING - Indicate what is used to monitor the interstitial space. Cc LTDC TRIGGERS AUDIBLE AND VISUAL ALARMS - Indicate Yes or No 490-65. VII -1 ELD TESTING -Check the box if you have been notified by the Stam Water Resources Cov -.. E ::....'- subject to Enhanced Leak Detection Requirements (i.e., UST has any single-•.^" ~--- --' ` ' .. , , • . • _ _. -. -- _-- 490-66. TESTING OF SECONDARY CONTAINMENT COMPONC. - . �. _ -•--_. =- --•- -- . - - - -+-- . - e 490-67. SPILL BUCKET TESTING - Check the box if you have spill 490 -68a -h. VIII RECORDKEEPING -Indicate r:•!•.:_`_ -_mow-o __' _" `; _"" "- . -- _'" ` " ` •':" ' ":- �_� . 490-69a IX TRAINING STATEMENT - Check the box to verify that the statement is true. _-OCUMENTS MAINTAINED AT FACILITY -Check the appropriate boxes to describe reference documents maintained at the facility. Note that the - - time list must be kept at the facility. ^• "• ^"•*� ^t "*r r^airnte that this plan is kept as a reference document •'C^ f-L`'CT40NIC EQUIPMENT: Indicate that this plan is kept as 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-W.. STATE WATER RESOURCES CONTROL BOA=_ STATISTICAL INVENTORY RECONCILIATION - Ir ;,-A- 0-w sr.;- ;e'"^' 490-69g.SWRC13 PUBLICATION:"LINDAeTA`Dnrn_ ^^ ^! ^T• Ott r a:^• •t•••t ^•tier reference documents are kept ^^ ^ ^^^^•* ' ""^""'^^ _ -`=^y ^_ter a brief description of the other document(s) maintained at the facility. If additional space is needed, see Section X. verify that this statement is true- -4 k,'AT!t)N - rue- r4k,'AT!t)N_ Make prittitir,nal comments or you may attach and identify the number of additional pages of information to describe ,,,t,r;tkmst i- miation required by your local agency). Attach any monitoring lops 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 maintena 490.73. TTTLE - Enter the title of the person. 490-74. NAME -Enter the name of the second person, if applicable, who routinely conducts the monitoring and equi-n-0 mA myna„^? imd?r this "lar 19075. Term t: E - ^•ar,tie title ofthe second person. - Inn V,_,.r A •rr m_E ne !mk owner/operator, facility owner/operator, or an authorized representative of the owner shal l sign in the space provided. .- : saccurate, ubmitted is true, accate, and complete. and that the training program specified in Section IX has been implemente.Td. + _ •5 :: ••� *ATG - y �!^p"priate Lax 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 date 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 (12/2007) 4/4