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<br /> Jar - UST Monitoring Plan - Page "I Instructions -
<br /> Complete aseparate UST Monitoring Plan for each UST monitoring system at the facility . This fotnr must be submitted with your initial US
<br /> Operating Permit. Application and within 30 days orchanges in the `infonnation it contains. Please note_ahat your local agency may require you
<br /> 1. robtain approval rior to installing or modifying monitoring equipment. (Nota:; Numbering of these instructions follows the data element numbers c
<br /> the form.)
<br /> MO ) . TYPE OF ACTION — Check the appropriate box to indicate why this plan is being submitted..
<br /> M02. PLAN •TYPE - Check the appropriate box to indicate whether this plan covers all, or merely some, of the USTs at the facility. If the plan covers on
<br /> some of the tanks, identiy those tanks in the space provided (e.g., by wing the Tank M N(a) in item 432 of the UST Operating Permit Application
<br /> Tank Form(s)]. - - - . - -. .
<br /> FACILITY m NUMBER - This spaceis for agency use only. - - t
<br /> M03. FACILITY NAME — Enter the complete Facility Name,
<br /> 004. FACILITY SITE ADDRESS — Enter the street address where the facility is located, including building number, if applicable. Post office box nualae
<br /> are not acceptable. This information must provide a means to locate the facility geographically.
<br /> MOS. CITY Enter the city or unincorporated area in which the facility is located, -
<br /> M06. MONITORING EQUIPMENT IS SERVICED — Checked the appropriate box to specify the frequency of monitoring 'equipment testing/ccnification.
<br /> M01.- SPECIFY If item I1-99 is checked,' enter the frequency of monitoring equipment testing/cenifteation.
<br /> MIO. TANK MONITORING METHOD(S) — Check the appropriate box(es) in Section IV to identify all required methods used for monitoring USTt
<br /> covered by this plan.
<br /> M 11 , SECONDARY CONTAINMENT IS =Cbeck the appropriate box to describe the environment inside tank secondary containment.
<br /> M 12, PANEL MANUFACTURER —. If item, IV- 1 is.ehecked, enter the name of the manufacturer of the-monitoring system control panel (console).
<br /> h113, MODEL N =If item N- I is checked enter the model number Cor the It monitoring system control panel.
<br /> M14. LEAK SENSOR MANUFACTURER:- If item IV- 1. is checked, enter the name of the manufacturer of the sensor(s). If additional space is needed , u
<br /> Section D:.
<br /> M15. MODEL N(S) — If item II is checked, enter the model number for cacti type ofsemor installed. If additional space is needed, use Section IX.
<br /> M16, PANEL MANUFACTURER =7f item IV-! is checked, enter the name of the manufacturer of the monitoring system control panel (console).
<br /> M17, MODEL .g - If item IV-2 is checked,' enter the model nurpbcr for the monitoring system control panel.
<br /> M 18, IN-TANK PROBE MANUFACTURER — If item IV-2 irchecked, enter the name of the manufacturer of the probe(s).
<br /> M19, MODEL N(S) — If item II is checked, enter the modeiItumber for each type of in-tank probe installed. If additional space is needed, use SccIioil 1,1
<br /> M20. LEAK TEST FREQUENCY - 1f item IV-2 is'checkcd, check the appropriate box to describe the in-tank leak test frequency.
<br /> h12l . SPECIFY —. If item M20 e, is checked crier the frequency of p(ogrammed leak tests.
<br /> M22. PROGRAMMED TESTS- If item IV-2 is cliecked;'check lhe'appiopiiaie box to describe the tests programmed into the ATG system. -
<br /> M23. SPECIFY— If item M224 is checked,entcr the frequency of in-tank leak testing. .
<br /> M24. INVENTORY RECONCILIATIONIfitem IV-3 is checked,- chuckthe appropriate box to describe the type of inventory recogciliation perforin
<br /> (i.e., Manual or Statistical). -
<br /> M25. TESTING PERIOD — If item IVA is pheeked, check the appropriate box to describe the MTG testing period. -
<br /> M26. TEST FREQUENCY t--If item IV-5;is checked, check The appropriate box to describe the frequency of tank integrity testing.
<br /> M27. SPECIFY — If item IV.5-c is checked, enter the frequency of lank integrity testing. " " - - - I : I , t I .
<br /> M28. SPECIFY — If item IV-99 is checked,enter a brief description of the other tank monitoring method(s) used (e.g.. vadose zone monitoring per 23 C(
<br /> §2647; groundwater monitoring per.23.. CCR.§2648). , Include the monitoring frequency (e.g., Continuous, Weekly). If additional space is ncedec, t
<br /> Section DC. .
<br /> M30. PIPE MONITORING METHOD(S) —. Check the appropriate box(es) in Section V to identify all required methods used for monitoring piping in
<br /> UST system(s) covered by this plan
<br /> + M31 , SECONDARY CONTAINMENT 1S - Check the appropriate box todescribe the environmentinside piping�ccondarycontainment.
<br /> M32, PANEL MANUFACTURER If item: V: I is checked,enter the name of the manufacturer of the monitoring system control panel (console).
<br /> M33. MODEL -N = If item V- 1 is'checked, enter the model number for the monitoring system control panel. � " -
<br /> M34, LEAK SENSOR MANUFACTURER — If item V- 1 is checked, enter the name of the manufacturer of the sensor(s).
<br /> M35. MODEL N(S) — If item V• I is checked, enter the model number for each type of sensor installed. If additional space is needed, use Section I.N .
<br /> M36. W ILL PIPING LEAK ALARM TRIGGER PUMP SHUTDOWN? — If item V- I is checked, check Yes or No.
<br /> M37, WILL FAILUREIDISCONNECTION OF MONITORING SYSTEM TRIGGER SHUTDOWN? If item V- I is checked, check Yes or No.
<br /> M38, MLLD MANUFACTURER(S) — If item V-2 is checked, enter the name(s) of the manufacturer(s) of the mechanical line leak detector(s). If addi :io
<br /> space is needed, use Section IX. I -
<br /> b139. MODEL N(s) — If item V-2 is checked, enter the model number for each type of mechanical line leak detector installed. If additional space is need
<br /> use Section DG 1 t r .
<br /> M40, ELLD MANUFACTURER'- If item V-3 is checked, enter the name of the manufacturer of the electronic line leak detector(s), .`
<br /> M41 . MODEL N(S) If nem V-} is checked, enter the model :number for each type of electronic line leak detector installed. If additional spate is needed,
<br /> Section ll:. - -
<br /> I M42, PROGRAMMED LME INTEGRITY TESTS — if item V-3 is checked, check the appropriate box to describe the type of tests programmed into
<br /> monitoring system. ik 4 1
<br /> M49 . WILL ELLD DETECTION OF A PIPING LEAK ALARM TRIGGER PUMP SHUTDOWN? — If item V-3 is checked, check Yes or No.
<br /> M44, WILL ELLD FAILURE/DISCONNECTION TRIGGER PUMP SHUTDOWN? - If itemV- I is checked, check Yes or No.
<br /> M45. TEST FREQUENCY — If item V-4 is checked, check the appropriate box to 'describe the frequency of pipe integrity testing.
<br /> M46. SPECIFY — If item V-4-c is checked, enter the frequency of pipe integrity testing)
<br /> M47. VISUAL MONITORING DONE — If item V-5 is checked; check the appropriate:box to describe the frequency of visual monitoring.
<br /> M48. SPECIFY - If item V-99 is checked, enter a brief description of the other line monitoringmethod(s) used. - if additional space is needed, use Sect
<br /> LK. Be sure to clearly describe monitoring method(s) and frequency. , -
<br /> .. i ",k. r* I.. .. ... ... . ...
<br /> This monitoring plan must include e' Site Plan showing the general lank and piping layouts and the locations where monitoring is performed lite., locatiot
<br /> each sensor, line leak detector, monitoring system control panel, etc.). If you already have a diagram (e.g., current UST Monitoring Site Plan Prot
<br /> Monitoring System Certification form, Hazardous Materials Business Plan map, etc.) which shows all required information, include it with this plan.
<br /> SJCEH D=d (07/03) o2/4 - 07/23/
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