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04/1712008 20: 05 5107963470 SHARMA PAGE 04 Qq, 4- s 08eeey Use Only) This plan has been reviewed grid 2rAp�proowed ❑Approved With Conditions j�17isappmvcd Local Agency Signature: /Nli(LVIr GZ1 c I` �C�!�`��`` Date: Comments or Special Conditions: UPCk UST Monitoring Plan— Page 2 Instructions Complete a separate UST Wmtoring 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. Plcasc 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 forma) 490-54a. MONI1 ORII3G c)• I E UNDER DISPENSM CONT.AINMEIT-Indicate We method used for UDC monitoring. 490-54b- SPECIFY-If 99"Other"is checked describe other method used. If VI-I-t,VI-1-2 or Vl-1-3 or'T-1-99 is checked complete 490-55 to 490-64b.490-55. PANEL NiANUFACTURER Ever the name of the manufacturer of the monitoring system control peaet(console). If there is no control panel(ejt„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 papal(e.g.,only an electrical relay box is installed)leave Ibis space blank 490-57 LEAK SENSOR MANUFACTURER-Enter the name o£the manufacturer of the sensor(s). 490-58. MODEL O(S)-Enter the tnodel number of the sensor(s)installed.If additional space is needed,use Section X. 490-59_ DDI TECTION OF A LEAK(NFO THE UDC TPJGrFERS AVDIBLE AND VISUAL ALARMS, Indicate Yes or No, 490-60. UDC LEAK ALARM TRIGGERS PUMP SHUTDOWN.Indicate Yes or No. 490-61. FAILUR6/DISCONNECTION OF UDC MONITORING SYSTEM TRIGGERS AUTOMATIC PUMP SHUTDOWN-Indicate Yes or No. 49062. UDC MONITORING STOPS THE FLOW OF PRODUCT AT THE DISPENSER-Indicate Yes or No. 49063. UDC CONSTRUCTION Iodicine if the construction of the UDC is single-wailed,or double-walled 490-64s. DOUBLE-WALLED INT16RSTMAL SPACE MONITORING-Indicate what is used to monitor the interstitial space. 490-64b.LEAK WITHIN THE SECONDARY CONTAINMENT OF UDC TRIGGERS AUDIBLE AND VISUAL ALARMS-Indicate Yes or No. 490-65, VII-I ELD TESTING-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(ice.,UST has any single-wall component and is located within 1 WO fact of a public drinking water well). 490-66, TESTING OF SECONDARY CONTALNNTNT CONIPONENI S EERY 36 MONTHS-Check the box if you have secondary containment that requires testing. 490-67 SPILL 13UCKET TESTING-Check the box i f you have spill buckets. 490668. VIII RECORDKETPTNG-indicate which monitoring and equipment maintenance rec:ords are maintained for this facitity. 490-69a. IX TRAINING STATEMENT-Check the box to verify that the statement is true. REFERENC'F.0O0_TNr6�.tTrs MAINTAINED AT FACILITY-Check the approprista boxes to describe fefereoce docrrraettts minatnitted at the faoility. Note that the first two items on the list must be kept at the facility. 490,69b. MONITORING PLAN:Indicate that this plan is kept as a mferetice document. 490-69c. OPERATING MANUALS FOR ELECTRONIC EQUIPMENT:Indicate that this plan is kept as a refcrcrice document. 490-69d. CA UST R17GULATIONS-Indicate that this is k"as a rc&muca document. 490-69e. CA LIST LAW-indicate that this is kept as a fefefenee document. 490-459f. STATE WATER RESOURCES CONTROL BOARD(SWRCB)PUBLICATION- "HAiNUriOUK f0K'fANK OWNERS—MANUAL AND STATISTICAL INVEI ITORY RECONCILIATION".Indicate that this is kept as a reference document. 490.698. SWRCB PUBLICATION?"UNDERSTANDING AUTOMATIC TANK GAUGING SYSTEMS Indicate that this is kept as a reference document. 490-69h. OTF3ER-Indicate that other reference doctmtents are kept, 490-69i. SPECIFY-If"OTHER"0 checked,enter a brief description of the other document(s)maintained at the facility,if additional space is needed,see Section X. 490.70. DESIGNATED()PPRATOR 7R,4TNiWG-Check this box to verify that this statement is true. 490-71. COMMENTS/ADDITIONAL INFORMATION-Make additinonal eommeuts or you may attach and identify the number of additional pages of information to describe auv additional UST system monitoritrg-relntod information(e.&,additional information required by your total agency). Attach any monitoring.logs that You will be using for the monitoring of your tank system 490-72. .NAM]e-Enter the name of the person who routinely condupts the monitoring and cquiprnerit maintenance under thin plem. 490-73. TITLE-Enter the title of the parson. 490-74. NANIE-Enta the name of the stwad pefsun,if applicable,who routinely conducts the monntodng and equipment maintenance under this plat!. 490-75. TITLE--Enter the title of the Second person. OVINER/OPERATOR SIGNATVIKE-The tank oNmer/operatnr,facility owncriopenttor,or an authorized representative of the owner shall sign in the space prmaded, This signature certifies that the signet believes that all information subtiliued 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 owncdoperatoi, the UST facility owner/opetmor, or an authorized representarlve of the owner. 490-77 DATE-Enter the date the plan was signed. 490-78. APPLICANT NAME-Print or type the nature of the person signing the plan. 490-79. APPLICANT TITLE-Enter the title of the person signing the plain, UFCF UST-B(112907)-414 www.nvidomwy