SITE INFORMATION AND CORRESPONDENCE

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uo i monitoring Plan — Page 2 Instructions Complete a separate UST Monitoring plan for each UST monitoring system at the facility. This forms rust be submitted with your inri , l L. Operating Permit Application and within 30 days of changes in the information it contains. Please note that your local agency ma obtain approval Prior to installing or modifying monitoring equipment. (Note: Numbering of these instructions follows the dam clement numue: < a the form.) 8 Y Y redlu ; rc you M50 DISPENSER MONITORING METHOD(S) — Check the appropriate box(es) in Section 1V to identify all required methods used to- snot, , nu the area(s) beneath the dispenser(s). If no dispensers are installed (e.g., USTs supplying :`. I51 . PANEL MANUFACTURER — If item VI- I is checked, enter the name of the manufacturer of generators), check item VI-5 , the monitoring system control pan;• I ( cor:, eb; If there is no control panel (e.g., only an electrical relay box is installed) leave this space blank. X152. MODEL 11 — If item VI- 1 is checked, enter the model number for the monitoring system control panel. if there is no controland _- electrical relay box is installed) leave this space blank. M53. LEAK SENSOR MANUFACTURER — If item VI- 1 is checked, enter the name of the manufacturer of the sensor(s). P M54. MODEL a(S) — If item Vl- I is checked, enter the model number for each type of sensor installed. If additional space is needed, use X155. RILL DETECTION OF A LEAK INTO UDC TRIGGER AUDIBLE AND VISUAL ALARMS? — If item VI- I is checked , check Yes er NI56. WILL A UDC LEAK ALARM TRIGGER PUMP SHUTDOWN? — Iritem> U7. "ILL FAILURE/DISCONNECTION OF UDC MONITORING TRIGGER SHUTDOis cked, check Yes or No. ,\ 158. ASSEMBLY MANUFACTURER — If item V1-2 is checked, enter the name of the mane cturer of he mechanlical leak detect on assembl , >159. MODEL x(S) — If item VI-2 is checked, enter the model number for each type of mechanical leak detection assembly space is needed, use Section IX. . 160. VISUAL MONITORING DONE — If item VW is checked, check the appropriate box to describe the frequency of visual monitoriayadV . t e'r. ; l :M61 . SPECIFY — If item VI-99 is checked, enter a brief description of the other mehod(s) used to monitor the UDC. If addiuonA space r; nere v. r use Section IX. . 170. ENHANCED LEAK DETECTION — Check the box if you have been notified by the State Water Resources Control Brand S \VRA UST(s) covered by this plan is/are subject to Enhanced Leak Detection Requirements (i.e., UST has any single-wall component ane! is rh .! I Ov within 1 ,000 feet of a public drinking water well). ( -- B) !n : t the M80. REFERENCE DOCUMENTS MAfNTAINED AT FACILITY — Check the appropriate boxes to describe reference documents mamtaired the facility. Note that items I , 2, and 3 must be kept at the facility. it < I81 . SPECIFY — If item VIII-99 is checkedter a brief description of the other document(s) maintained at he facility. If additional needed, use Section IX. .vISS. CO:SIMENTS/ADDITIONAL INFORMATION — You may use this section to describe any additional UST system monitoring - i r� ;: mr' in formation (e.g., additional information required by your local agency). If using Section IX as additional space for items requrnd el ;e •.• 6r, in this Plan, reference the item number (e.g., "Item M54 - Model 2468 and 3579 Leak Sensors"). 014'NER/OPERATOR SIGNATURE — The owner/operator shall sign in the space provided. This signature cemlics that the srenrr behr . e , that all information submitted is true, accurate, and complete, and that the training program specified in Section Vill has been impL••memec .\ 190. REPRESENTING — Check the appropriate box to indicate whether the signer is representing the UST owner or UST operator. M91 . DATE — Enter the date the plan was signed. 5192. O WNER/OPERATOR NAME — Print or type the name of the person signing the plan. I U93, OIVNER/OPERATOR TITLE — Enter the title of the person signing the plan. %i 1 SJCEHD-d (07/03) - 4N