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11/19/2008 12:51 FA.1 9163712540 BZMAINT @i 009 UST Monitoring Plan—Page 2 Instructions submitted with ore Initial UST at do(agility This form must U i Complete a separate UST Monitolini.Plan for each UST monitoring system cor m require u to days of changes in the information it contains. please tote that y j local agency Ay YO Operating Permit Application and within 30 4 data element numbers on obtain approval plipt to installing or modifying monitoring equipment. (Note: Numbeting of these instructions tiollows the the form.) M50,DISPENSER MONITORING METHODS)—Check the appropriate bOX(es)in Section IV to identify all r6qtfired methods used for mim'dtoring the area(s)beneath the d' s). If no dispensers are installed(e.&.USTs supplying standby generator$),check.item VI-5, M51, PANEL MANUFACTURER—If item VI.I is checktA enter the name of the manufacturer Of the monis eril g systems control Panel(console)- Ifthere is no wlk*l panel(r.&,only an electrical relay box is installed)two this space,blank. con" enumber for the monitoring system controlpanel,If ther';Is no I P"(e-g-,04Y as M52. MODEL If km VI-I is checked,cuter tho model . I electrical May box is Installed)leave this space blank. sor M33.LEAK SENSOR MANUFACTURER—If iters VI-1 is checked,enter the name Of the mmu of -1 0 (so a) is aceded,use Section IX. ' M54.MODEL#(S)—If Item VI-1 is chwkc4 enter the model number for each type of sensot installed.If sdditisp B M55.WILL DETECTION Or A LEAK INTO UDC TRIGGER AUDIBLE AND VISUAL ALARMS?—If starts V11-1 is chocked,check Yes or No. cho&.4 M56.WILLA IIDC LEAK ALARM TRIGGER PUMP SHMOWN?—If item VI-1 is ab_Ieotkmyos10rj1schecked,c ,checkytsorNO - - M51.WILL FAILUREIDISCONNECTION Or UDC MONITORING TRIGGER,SHUTDOWN? 1 h�nical leek detection assembly. M58.ASSEMBLY MANUFACTURER—if item VI.2 is checked,enter the new ofthg manufacturer of the meb model number for each type of mechanical leak dgtcc0o6 asweft*installed-If additional M59.MODEL 40(S)—If item VI-7 is charkcd,eater the � I space is needed,use Section IX item VI-3 is checked,check the appropriate box to describe the fivqVc I Pey Of visual monitoring. M60.VISUAL MONITORING DONE —If M61.SPECIFY—If item VI-99 is checked,enter a brief description of the other method(s)used W monitor the'UD, C. if additional space is needod, use Seotion TX M10.ENHANCED LEAK DETECTION —Check the box if you have been notified by the State Water Resouroci ContrOl Board(SWRCR)that the UST(s)covered by this plan is/arc subject to D,ihancod Leak Detection R90=40ts(i.e.,UST has any�Wwall cemponent and is located Within 1.000 foot of a public dritAing Water well), M80,REFERENCE DOCNTS AINED AT rACILM—Check the appropriate box=to describe fereace documents maintained at UNGMAINT the ficility. Note that items 1,2,PA 3 be kept at the facility. other dowment(s)rn&inWi=a:at1 the facility,if additional space is Mal brief description of the SpECIFy—If item Vjjj�qq is checked.critor a needed.use Section IX- local&9@r— you may.use this section desuc anaddltia4 UST system mcnitoring-rswhelated M85, COMMENTSIADDITIONAL INFORMATION q), If wingto SectionibIX asy additional ispacc for items required elsere information(e.g.,additional information required by your in this plea,reference the item number M54-Model 2469 and 3579 Leg SWWW'). ONANERIOPERATOR SIGNATURE—The owner/operator shall sip in the space pmvided. This signprm Certifies that the siper believes urste,and*=plate,and that ft training pro@vm specWcd in Ste on VM has been imPI0McDtcd-- that an info on submitted is true,acq . 1, m90,REPRESENTING—Check the appropriate box to indicate whathor the signer is representing the UST Owner or UST operator. M91.DATE—Enter the date,the plan was sigad_ the nine of the person gigaing the plan, M92,OWNERIOPERATOR NAME—Print or" M93,OWNER/OPERATOR TITLE—Enter the Coe of the person signing the plan. 07MM3 SSCEIED60(07,03)-4/4