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• • (Agency Use Only) Ihis plan has been reviewed and: ❑ Approved ❑ Approved With Conditions ❑ Disapproved Local Agency Signature: Date: Comments or Special Conditions: UPCF UST Monitoring Plan — Page 2 Instructions Complete a separate UST Monitoring Plan for each USI 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 poor 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 - Indicate the method used for UDC monitoring 490-54b SPECIFY — It 99 "Other" is checked, describe other method used If VI -1-1, VI -1-2 or VI -1-3 or VI -1-99 is checked, complete 490-55 to 490-64b 490-55 PANEL MANUFACTURER —Enter the name of the manufacturer of the monitoring system control panel (console) If there is no control panel (e g , only an electrical relay box is installed) leave this space blank 490-56 MODEL # — Enter the model number for the monitoring system control panel (console) If there is no control panel (e g, only an electrical relay box is installed) leave this space blank 490-57 LEAK SENSOR MANUFACTURER — Enter the name of the manufacturer of the sensor(s) 490-58 MODEL, #(S) — Enter the model number of the sensor(s) installed If additional space is needed, use 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 FAIL URE/DISCONNECTION OF UDC MONITORING SYSTEM TRIGGERS AUTOMATIC PUMP SHUTDOWN— Indicate Yes or No 490.62 UDC MONITORING STOPS IHE FLOW OF PRODUCT AI THE DISPENSER - Indicate Yes or No 490-63 UDC CONSTRUCTION - Indicate if the construction of the UDC is single -walled, or double -walled 490-64a DOUBLE -WALLED INTERSTIIIAL SPACE MONITORING — Indicate what is used to monitor the interstitial space 490-64b LEAK WITHIN THE SECONDARY CONTAINMENT OF UDC TRIGGERS AUDIBLE AND VISUAL ALARMS — Indicate Yes or No 490-65 VII -1 ELD TESTING — Check the box if you have been notified by the State Water Resources Control Board (SWRCB) that the UST(s) covered by this plan is/are subject to Enhanced Leak Detection Requirements (i e, USI has any single-wall component and is located within 1,000 feet of a public drinking water well) 490-66 IESTING OF SECONDARY CONTAINMENT COMPONENIS EVERY 36 MONTHS — Check the box if you have secondary containment that requires testing. 490-67 SPILL BUCKET IESTING — Check the box if you have spill buckets 490-68 VIII RECORDKEEPING — Indicate which monitoring and equipment maintenance records are maintained for this facility 490-69a. IX TRAINING STATEMENT — Check the box to verify that the statement is true REFERENCE DOCUMENTS MAINIAINED AT FACILITY —Check the appropriate boxes to describe reference documents maintained at the facility Note that the first two items on the list must be kept at the facility 490-69b MONITORING PLAN: Indicate that this plan is kept as a reference document 490-69c OPERATING MANUALS FOR ELECIRONIC EQUIPMENT: Indicate that this plan is kept as a reference document 490-69d CA UST REGULATIONS — Indicate that this is kept as a reference document 490-69e CA USI LAW — Indicate that this is kept as a reference document 490-69f SIATE WATER RESOURCES CONTROL BOARD (SWRCB) PUBLICATION — "HANDBOOK FOR TANK OWNERS — MANUAL AND SIAIISTICAL INVENTORY RECONCILIATION": Indicate that this is kept as a reference document 490-69g SWRCB PUBLICATION: "UNDERSTANDING AUTOMATIC TANK GAUGING SYSTEMS": Indicate that this is kept as a reference document 490-69h OTHER — Indicate that other reference documents are kept 490-69i SPECIFY — If "OTHER" is checked, enter a briefdescription of the other document(s) maintained at the facility If additional space is needed, see Section X 490-70 DESIGNATED OPERAIOR TRAINING — Check this box to verify that this statement is true 490-71 COMMENTS/ADDITIONAL INFORMATION — Make additional comments or you may attach and identify the number of additional pages of information to describe any additional UST system monitoring -related information (e g, additional information required by your local agency) Attach any monitoring logs that you will be using for the monitoring of your tank system 490-72 NAME — Enter the name of the person who routinely conducts the monitoring and equipment maintenance under this plan 490-73 TITLE — Enter the title of the person 490-74 NAME— Enter the name of the second person, ifapplicable, who routinely conducts the monitoring and equipment maintenance under this plan 490-75 TITLE — Enter the title of the second person OWNER/OPERATOR SIGNATURE — The tank owner/operator, facility owner/operator, or an authorized representative of the owner shall sign in the space provided This signature certifies that the signer believes that all information submitted is true, accurate, and complete, and that the training program specified in Section IX has been implemented 490-76 REPRESENTING — Check the appropriate box to indicate whether the signer is the UST owner/operator, the UST facility owner/operator, or an authorized representative of the owner 490-77 DAIE — Enter the date the plan was signed 490-78 APPLICANI NAME — Print or type the name of the person signing the plan 490-79 APPLICANT TITLE — Enter the title of the person signing the plan UPCF UST -D (12/2007) - 4/4 www..unidoes.org