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02/05/2003 08:11 9163712450 BZ MANITANENCE PAGE 13/13
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<br /> UST Monitoring Plan—Page 2 justmetions
<br /> Complelo a separft UST Monitoring Plan for each UST monitoring system at the facility, This form must be submitted with your initial UST
<br /> Operating Permit Application and within 30 days of changes in the b1fomation it contains. Please note that your local agency may requir.You 10
<br /> obtain approval p,ftt.oinqLiii,lingormodifying monitoring oqtiipment- (P4otc: Nva boring of these irtstnictions frillowq the data element numbcrs on
<br /> the form.)
<br /> M50,DISPENSER MONT.TORJNO METBOD(S)—Chwk the appropriate bDx(cs)in Section IV to identify nil required methods used for monitoring
<br /> the area(s)beneath the dispenser(-.;). if no dispensers am installed(e.g.,USTs supplying standby generators),check item VI-5.
<br /> M51.PANEL MANUFACnJRER—If item VI-I is checked,enter the nano of the manufacturer of the monitoring system control Panel(COosolc)-
<br /> if them is no control parse)(c.g.,only on electrical relay installed) space
<br /> . box is i. s lled)leave this blank.
<br /> V- 52.MODEL ft—If item VT-I is checked,enter the model number for the monitoring system control panel.If there is no control panel only an
<br /> electrical relay box is installed)leave this space blank
<br /> M53- LEAK SFNSOR MANUFACTURER—If item VT-I in checked.,enter the name of the rosti0acturer of the sensor(s).
<br /> M54,MODEL W(S)—If item VI-1 is checked,enter the model number for each type of sensor installed.If additional space is pooled,use Section YX
<br /> M55,1%17,L DETECTION OF A LEAK NrO UDC TRIGGER AUDIBLE AND VIsVAL ALARMS?—If item VI-I is checkcd,check Yes or No.
<br /> M56, WILL A UI)C TXAX ALARM HUGGER.PUMP SHUTDOwN7—if item V14 is chocked,check Yes oir No.
<br /> M57,WILL FAILUREIDISCONNECTION OF UDC MONTTc)prgG TRIG<3EV.SHUTDOWN?—if item VI-1 is checked,check Yes or No.
<br /> M58,ASSEMBLY MANUFACnrAER—If item V14 is cliecked,enter the name of the marnijactw&of the mechanical leak detection assemb'ly,
<br /> M59. MODEL O(S)—If item VI-2 is checked,enter the model number for each type of mechar3cal leak detection assembly installed.If additional
<br /> space is needed,use Section TX
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<br /> M60.M60.VISUAL MONYTORNG DONTI —If item VT-3 is chocked,cbcck the appropriate bfmqjiaox to describe the cy of visual monitoring,
<br /> M. 0 ,needed,
<br /> 61,SPECIFY—If item VI-99 is checked,enter a brief degeriptiou of the other metbod(s)used to monitor the UIX, iradditionalspae is
<br /> use Section IX
<br /> M70.E-NHANCED LEAK DETECTION —Check the box i ryou have been notified by the State Water Resources Control Board(SWRC13)that the
<br /> ;single-wall UST(s)covered by this plan ix/are subject to Enhanced 1,-ak Detection Requirements(i.e.,UST bas any c .gle-wall component and is located
<br /> within 1,000 ft-ct of a public drinking water well).
<br /> M80.REFI-1ZENCE DOCUMENTS NLAMtAINED AT FACILITY—Chock the appropriate box"to describe reference documentsrnairitained at
<br /> ttc facility. Note that items 1,2,and 3 Mlgt be kept at the facility. acility. If ndditional 5POcc i,',
<br /> gl.SpECIFy—If item VIII.99 is checked,enter a brier description of the other document(s)maintained at the r
<br /> needed,use Section IX.
<br /> N195. COMMENTSIADI)MONAL TNT-01UN4ATION — You may use this section to demeril5e any additional UST system monitoring-rcl%ted
<br /> If using Section JX a additional space for items required Clft-Abwc
<br /> information(e.g.,additional information required by your local agency).
<br /> in this plan,reference the item number(e.g,"Item M54-Model 2468 and 3579 Leak Sensors").
<br /> CWNEIvOPERA'TOR SIGNATURE—The towner/operator shall sign in the spece provided. This signature certifies 4,bat the signer believes
<br /> that all information submitted is M,a0wrat',and complete,and that the training prograrn specified in Scojon VM has been iTriplemeatcd.,
<br /> M90.0. REPRESENTING—Check the Appropriate box to indicate wbodw the signer is representing the UST owner or UST operator.
<br /> tor.
<br /> M91.DATE--Enter the date the plan was signed.
<br /> M92.OWNER/OPERATOR NNW,—Print or type the name of the person signing the Plan,
<br /> M93.OWNER/OPERATOX TME—Enter the tifie of the PermOn signing the Plan-
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