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t Y"R here i'} V' ' T V: } ib kid Agcy . T,tate J o P z UST Monitoring P —Page 2 Instructions Complete a separate UST Monitoring Plan for each UST monitoring system at the facility This form must be submitted with your initial UST Operating Permit Application and within 30 days of changes in the information it contains. Please note that your local agency may require you to obtain approval gdQr to installing or modifying monitoring equipment. (Note: Numbering of these instructions follows the data element numbers on the form.) 490-54a MONITORING OF THE UNDER DISPENSER CONTAINMENT Indite the method used fbrUDC maxi 490-54b. If 99 is checked,describe other method use If VI-1-1,VI-I-2 or VI-1-3 or VI-1-99 is decked,complete 490-55 to 490-64b. 490-55. PANEL.MANUFACTURER—Enter the name of the numullicturw of the monitoring system control pod(console) If thee is no control panel(erg.,only an electrical relay box is installed)leave this space blank. 490-56. MODEL# Enter the model numb for the monitoring system control panel(console).If thine ism control panel(eg.,only an electrical ical relay boar is installed)leave this space blank. 490-57. LEAK SENSOR MANUFACTURER—Enter the time ofthe menufticturer of the sehsor(s). 490-S8. MODEL#(S)—Enter the model number of the s)Installed.If additional space is needed,we Section X. 490-59. DETECTION OF A LEAK INTO THE UDC TRIGGERS AUDIBLE AND VISUAL ALARMS. Indicate Yes or No 490-60. UDC LEAK ALARM TRIGGERS PUMP SHUTDOWN Indicate Yes or No 490.61. FAILUREIDISCONNECTION OF UDC MONITORING SYSTEM TRIGGERS AUTOMATIC PUMP SHUTDOWN Indicate Yes or No 490-62. UDC MONITORING STOPS THE FLOW OF PRODUCT AT THE DISPENSER Indicate Yet or No. 490-63. UDC CONSTRUCTION- Indicate ifte construction ofthe UDC is singlewalled,or double-walled. 4 DOUBLE-WALLED INTERSTITIAL SPACE MONITORING-Indicate what is used to mondor the"interstitial spade 490.64b.LEAK WITHIN THE SECONDARY CONTAMEENT OF UDC TRIGGERS AUDIBLE AND VISUAL ALARMS-Indicate Yet or No 490.65. VII-I ELD TESTING Check the box if you(rave been notified by the State Waw Resources Central Board(SWRCB)that the UST(s)covered by this plan Was adtic a to Enbanced Leak Detection Requirements(ie.,UST has any sintglewall component and is located within 1,000 feet of a public dtinking water well} 490-66. TESTING OF SECONDARYCONTAINMENT COMPONENTS EVERY 36 MONTHS Check the box if you have secondary containment that requiriss uwm& 490.67, SPILL BUCKET TESTING Cheek the box ifyou have spill 4 .VIII RECORDKEEPING-Indictee which monflaring and equipment maintmance records am manditined for this fatality 490.69a IX TRAINING STATEMENT Check the box to verify that the statement is mss REFERENCE DOCUMENTS MAINTAINED AT FACILITY—Check the appropriate bom to describe reference documents maintained at the thcility. Note that the first two items on the list mo be kept at the facility. 490-69b. MONITORING PLAN:Indicate that this plan is kept as a reference document. 490.69c, OPERATING MANUALS FOR ELECTRONIC EQUIPMENT-Indicate that this plan it kept as a i 490-M CA UST REGULATIONS-Indices that this is kept as a reference docummLI 490-69e. CA UST LAW Indicate that the is kept as a rekrence document 4%-690 STATE WATER RESOURCES CONTROL BOARD(SWRCB)PUBLICATION "HANDBOOK FOR TANK OWNERS MANUAL AND STATISTICAL INVENTORY RECONCILIATION Indicate that this is kept as a reference documeta. 4 SWRCBPUBLICATION-"UNDERSTANDING AUTOMATIC TANK GAUGING SYSTEMS":Indicate that this is kept as a 490-M OTHER Indicate that other raftencii documents are kept. 490-691. S -If"OTHER is checked,enter a briefdescription ofthe other s)maintained at the facility.Ifadditional space is needed,we Section X. ' 490-70. DESIGNATED OPERATOR TRAINING Check this box to verify that this statement is true. 490-71. CO ADDITIONAL INFORMATION—Make additional comments or you may attach and identify the member ofadditional paps of inflammon to docnbe airy additional UST en(erg.,additional information by your local ). Attach any monitoring logs that you will be using for the monitoring ofyour tank 490-72. NAME—Enter the name ofthe person who routinely conducts the monitoring and etpupoicatmaintimance undathis Alen, 490-73. TITLE Enter ten title of the 490-74. NAME—Enter ffic name ofthe second person,il'applicable,who routinely conducts the monitoring and equipment maintenance under this plan. 490-75. TITLE Enter the title ofthe second persim. OWNERA)PERATOR SIGNATURE—The tank ownedoperalor,facility owner/operator,or an authorized representamofthe owner shall sigh in the space This signaturecertifies that the s' bel" flet all in is provh true, and complete,and the ' ' g 'find o IX has been 490-76. REPRESENTING—Check the Wmpim bent to indicate whether the super it the UST owner/operabor,the UST facility ownedoperator,or an audwrized representative of the owner. 490-77 DATE—Enter the date the plan was signed. 490-79. APPLICANT NAME—Print or type the nae ofthe person signing the 490-79 APPLICANT TITLE—Enter to title offlieparm sqViing' i i UPCF UST-D( 414