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10/06/2011 08:09 2099316743 waterloo Food Mart #0720 P.006/015
<br />(AgMO Use Only) This plan n reviewrrd pd., pproved Q Approved Witb Conditions ❑ Disapproved
<br />Local Agency Signature: Date;
<br />Comments or Special Condiri
<br />UPCF UST Monitoring Pian -- Page 2 Instructions
<br />CvtuJJI (, a a..pw.U- UST T`141 Foe c.a:.lt UGT ...V„ity, uit ayot;.7t at the facility_ T-hia form moot be aarbmittod with yaur initial UST
<br />llr..r.t;r,o Pr, -.,.;f Artrl;ratie n anti w;th;n In AAyv ni` rhsen,pr.¢ :n Ih�.:rtfixmatinn it rnnrnina Plrnar. nntn that ynetr 1c -.nl ngmrW mny "iiia yn„ t�
<br />obtain approvalrp for to installing or modifying monitoring equipment (Note: Numbering of these instructions follows the data clement numbers on
<br />the form.)
<br />490-54a. MONITORING OF THE UNDER DISPENSER CONTAINMENT - Indicate the method aced for UDC monitoring.
<br />490-54b. SPECIFY - If 99 "Other"' is chocked, describe other method used.
<br />If VI -I.1, VW -2 or VI.1-3 or Vbl-99 is checked, complete 490.55 to 490.64b,
<br />494-53. F v33PL 4L1t1ilFACFEJitER - Eau a IIIc coots of iLe ntweuCat tu[u vCtfw 7uu3uwtiug �ysto[u wee7tvl p u�el (wnsole). !t tlrt,t is [[u �vuuvi y+u[el (o.g., vtdr ssu elwuiusl
<br />relay box is installed) leave this space blank
<br />.100.55. r.nnnv r1 _ 4..,-. dt ..,.-7.1 I. ell rh. -4 e.. my
<br />this space blank.
<br />490-57. LEAK SENSOR MANUFACTURER - Enter the name of the manufacturer of the semor(s).
<br />490-58. MODEL 1#(S) - Enter the model number of the sensor(s) installed. If additional space is needed, use Section X.
<br />490-59, DETECTION OF A LEAK iNrO T1,W UDC TTUGGE" AUDIBLE AND VISUAL ALARMS. Indicate Yes or No.
<br />490-60. UDC LEAK ALARM TRIGGERS PUMP SHUTDOWN- indicate Yes or No.
<br />490-61_ t'AILUKtA) iCUNNEA:I'ION OF (31X: MUNI IUKINU S YJ'I'EM J K1(iCib:KS AU I'UMA l IC 11UMF JHLJ IDUWN-lnotcaic Ycs or No.
<br />490-62. UDC MONITORING STOPS THE FLOW OF PRODUCT AT THE DISPENSER - Indicate Yes or No,
<br />490-63. UDC CONSTRUCTION - Indicate if the construction of the UDC is single -walled, or double -walled.
<br />490-454a. DOUBLE-WALLFD INTERSTITIAL SPACE MONITORING - Indicate what is used to monitor the Interstitial space.
<br />490�4b. LEAK WITHIN THE SECONDARY CONTAINMENT OF UDC TRIGGERS AUDIBLE AND VISUAL ALARMS - Indicate Yes orNo,
<br />490-65. Vll-I ELI)TESTING - Check the box if you have been notified by the State Water Resources Control Board (SWRCS) that the UST(s) coveted by this plan is/are
<br />490-66_ TESTING OF SECONDARY CONTAINMENT COMPONENTS EVERY 36 MONTHS - Check the box if you have secondary containment that requires testing.
<br />490-67. SPILL BUCKET TESTING - Check the box if you have spill buckets.
<br />490-68. VIII RECORDKEEPING - Indicate which monitoring and equipment maintenance records are maintained for this Facility.
<br />400-69a- W TRATNW(i cT kT13MENT - Ch?clr rhe Mx t0 v? ify that the statement is true.
<br />Xh-khkCLNCh iA)CUMt1VIJ MAIN I A1NIsU A 1 17ACLLt IY - (heCIC the appropriate boxes to oescrtbe reference documents mauttamed at the facility. Note that the
<br />first two items on the list = be kept at the facility.
<br />490-69b- MONITORING PLAN: Indicate that this plan is kept as a reference document
<br />490-69c. OPERATING MANUALS POI, ELECTRONIC EQUIPMENT: Indicate that this plan is kept as a rcfcretxc document
<br />490-69d_ CA UST REGULATIONS - Indicate that ibis is kept as a reference document
<br />490-69e. CA UST LAW - Indicate that this is kept as a reference document.
<br />490-69f. STATE WATER RESOURCES CONTROL BOARD (SWRCS) PUBLICATION- "HANDBOOK FOR TANK OWNERS _ MANUAL AND
<br />STATISTICAL INVENTORY RECONCILLATION": Indicatethat this is kept as a reference document
<br />490-698- SWRCB PUBLICATION; "UNDERSTANDING AUTOMATIC TANK GAUGING SYSTEMS": Indicate than ibis is kept as a reference doctunent.
<br />490-69h. OTHER - Indican rust other reference documents are kept.
<br />49t}69i. SPECIFY - If "OTHER" is chtk-ked, enter a brief description of the other docta wnt(s) maintained at the facility. If additional space is needed, see Section X
<br />490-70, DESIGNATED OPERATOR TRAINING - Check this box to verify that this statement is true.
<br />490-71. COMMENTS/ADDITIONAL INFORMATION - Make additional cornments or you tray attach and identify the number of additional pages of information to describe
<br />any additional UST system monitoring.felated information (e.&, additional information required by your local agency). Attach any rnonitonng logs that you will be
<br />using for the monitoring of your tank system
<br />49042. NAME - Enter the name of the person who routinety conducts the nxmimrine. and equipment maintenance tinder thin plan
<br />490-73. TITLE - Enter the title of the person.
<br />490-74. NAME - Enter the name ot the second person, it appirca.01e, who routinely conducts the mentoring and equipment maintenance oWer t1us plan.
<br />490-75. TITLE - Enter the title of the second person.
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<br />Thi. ro,t:As <i4n r Frli..,.a rl... ,.r[ �-C, ...,.. 4-, ,-..k_,ittw.k :v N.w.:.c:-..tart, and l.N.r, and .a.ax aao zrofntn
<br />comp g progw,w. opooited in Loaeoo ut ha,
<br />been implemented.
<br />490-76. REPRESENTING - Check the appropriate box to indicate whether the signer is the UST owner/operator, the UST facility owncr/operator, or an authorized
<br />representative of the owner.
<br />490-77. DA.TF - Enter the date the plat was signed.
<br />490-78. APPLICANT NAME - Print or type the name of the person signing the plan
<br />490-79. APPLICANT TITLE - Enter the title of the person sighing the plan_
<br />UPCF UST -D (1:12007) - 4/4 www unjdomorg
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