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Mar 071011:11a ArPminimartp 2098352297 p.7 (:rgcroy(;,,e 0f_) This plan has been reviewed' d Approved ❑Approved With Conditions Local Agency Signature: t Date: Comments or Special Conditions: UST Monitoring Plan-Page 2 Instructions Complete a separate LIST Monitoring Plan for each LIST monitoring system at the facility. This form rust be submitted with your initial UST Operating Permil Application and within 30 days of changes in the information it contains. Please note that your local agency may require you to obtain approval pLiqLrto installing or modifying monitoring equipment (Note: Numbering of these instructions follows the data element numbers on the forms.) 490-54a.MONITORING OF THE UNDER DISPENSER CONTATNly T -Indicate the method used for UDC monitoring. 490-54b.S?ECIFY-109-Other,*is checked,describe other raethod used 1FVI-1.1,Vn-I-2 0-r ZR-I-3 or VI-I-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 no control panel(eg.,only an electrical relay box is installed)leave this space blank. 490-56. MODEL 4- Enter the model number for the monitoring system control panel(console) If there is no control panel(e.g.,only an electrical Tetay box is installed)leave this space blank. 490-57. LEAK SENSOR MANUFACTURER-Enter the name of rhe manufacturer of the sensor(s). 49x58. MODEL#(S)-Enter the madel number of the sensors)installed lfadditional space is needed,use Section X. 490-59. DETECTION OF A LEAK rNTO 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/DISCGNNECTION OF UDC MONITORING SYSTEM TRIGGERS AUTOMATIC PUMP SHUTDGbUN-Indicate Yes or No 490-62. UDC L&IONITORING STOPS THE FLOW OF PRODUCT AT THE DISPENSER-Indicate Yes or No. 490-63. UDC CONSTRUCTION- Indicate ifthe construction of the UDC is single-walled,or double-walled. 490-64a.DOUBLE-WALLED INTERSTITfAL SPACE MONFI.ORLNG- Indicate what is used to monitor the interstitial space. 490-64b.LEAK W ITHII4 THE SECONDARY CONTAIME NT OF UDC TRIGGERS AUDIBLE AND VISUAL ALARMS-Indicate Yes or No 490.65. VN-1 ELD TESTING-Check the box if you have been notified by the State Water Resources Control Board(SWRCB)that the UST(s)coverod by this plan israze 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>. 49x66. TESTING OF SECONDARY CONTAtNt iLtd r COMPONENTS EVERY 36 MONTHS-Check the box if you have secondary containment that requires testing. 490-67. SPILL BUCKET TESTING-Check the box ifyou have spill buckets 490-68a-h.VIII RECORDKEEPfNG-Indicate which monitoring and equipment maintenance records are maintained for this facility. 490-69a IX TRAINING STA-:'EMENT-Check the box to verify that the statement is true. REFERENCE DOCUMENITS MAINTAINED AT FACILITY-Check the appropriate boxes to describe referents documents maintained at the facility. Note that the first two items on the list mL_tst be kept at the facility. 490-69b. 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. 490-69d 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. 490-69C STATE WATER RESOURCES CONTROL BOARD(SWRCB)PUBLICATION- `-HANDBOOK FOR TANK OWNERS-MANUAL AND 3TAT09"CAI.INV ENTORV RECONCILIATION-Indicate that this is kept as a reference document 490-69&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"OTHER"is check-4 enter a briefdescription of the other documents)maintained at the facility.If additional spare is needed,see Section X. 490-70. DESIGNATED OPERATOR TRAINING-Check this box to verify that this stuicment is true. 490-71. COMMENTS/ADDITION.AL INFORMATION-brake additional comments or you may attach and identify the number of additional 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 of your tank system. 49042, NAME-Enter the name of the person who routinely conducts the monitoring and equipment maintenance under this plan- 49043. TITLE- Enter the title of the person. 490-74. NAME-Enter the name of the second person,if saplicable,who routinely conducts the monitoring and equipment maintenance under this plat, 490-75. TITLE- Enter the title ofthe second person- OWNER(OPERATOR SIGNATURE-The tank ownerbpcmior,facility owner!operator,or an authorized representative of the owner shall sign in the space provided. This signature certifies that the signer believes that all information,subr fitted 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 incicate whether the signer is the UST owner/operator,the UST Facility owner/operator,or an authorized rcpresentadve of the owner. 490-77. DATE-Enter the date the plan was signed- 490-79. APPLICANT NAME-Print or type the name of the person signing the plan. 490-79. APPLICANT TITLE-Enter the title ofthe per-on signing the plan. UPCF UST-I)(1212007)4(4