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202,8253893 ENGINEERING DE 0 1 p.m. 09-10-2010 6/6 t d � (Agency Use only) This plan has been reviewed and; ❑Approved ❑Approved With Conditions ❑Dimpproved Local Agency Signature: Date: Comments or Special Conditions; -� UPCF UST'Monitoxing Plan—Page 2 Instructions. Complete a separate UST Monitoring Plan for each UST monitoring system at the facility. This form must be submittal with your initial UST Operating Permit Application and within 30 days of changes intthe information it contains, Phxtsc note that your local agency may require you to obtain approval prior 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-If 99"Other"is checked,describe other method used. If VI-i-1,VI-1-2 or VI-1-3 or VI-1-94 is checked,complete 490.55 to 490.64b, 490-55, PANEL MANUFACTURER—Entcgthe name of the manuf"aeturcr of the monitoring system control panel(console). If there is no control panel(e.g,,only an electrical relay box is installed)leave this spade 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)—F,ntcr the model number of the settsor(s)installed.if additional space is needed,use Section K 490.5.9, DETECTION OF A LEAK INTO THE UDC TRIGGERS AUDIBLE AND VISUAL ALARMS. indicate Yes or No. 490-60, UDC LE*K ALARM TRIGGERS PUMP SHUTDOWN-indicate Yes or No. 490-61, FAILURE/DISCONNECTION OF UDC MONITORING SYSTEM TRIGGERS AUTOMATIC PUMP SHUTDOWN-indicate Yes or No. 490-62. UPC MONITORING STOPS TIME FLOW OF PRODUCT AT 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 RgEkSTITIAL SPACE MONITORING—Indicate what is used to monitor the interstitial apace. 490-64b.LEAK WITHIN THE SECONDARY CONTAINMENT OF UDC TRIGGERS AUDIBLE AND VISUAL ALARMS—Indicate Yea 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 islam subject to Enhanced Leak Detection Requirements(i.e.,UST has any single-wall component and is located within],NO feet ora public drinking water well). 490-66. TESTING OF VCONDARY CONTAINMENT COMPONENTS EVERY 36 MONTHS—Check the box if you have secondary containment that requires testing. I 490-67, SPILL BUCKET TESTING—Check the box if youpave spill buckets. 490-68. VIiI RECORDKEEPiNG—Indicate which monitapng and equipment maintenance records arc maintained for this facility. 490.69x. 1X TRAINING STATEMENT—Chuck the box 10 verify that the statement is true. REFERENCE DOCUMENTS MAINTAINED ATTACiLITY-•Check the appropriate boxes to describe reference documents maintained at the facility. Note that Ole 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 490.69e.OPERATING MANUALS FOR ELECTRONIC 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. 490-69c.CA UST LAW—Indicute that this is kept as a rcfercncc document. 490-69f. STATE WATER RESOURCES CONTROL BOARD(SWRCB)PUBLICATION— 'HANDBOOK FOR TANK OWNERS—MANUAL AND STATISTICAL INVENTORY RECONCILIATION":Indicate that this is kept as a reference document. 490-69g.SWRCS PUBLICATION:"UNDERSTANDING AUTOMATIC TANK GAUGING SYSTEMS":indicate that this is kept as a reference document. 490-69h.OTHER—Indicate that other refcren�e documents are kept. 490.69i, SPECIFY—if"OTHER"is checked,enter a brief description of the other document(s)maintained at the facility.If additional space is needed,see Section X. 490-70. DESIGNATED OPERATOR TRAINING—Check this box to verify that this statement is true. 490-71. COMMENTS/ADDITIONAL INFORMATION—Make additional comments or you tray allach and identify the number of additional pages of inrormation 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 wing for the monitoring of your tank system 490-72. NAME—Enter the name or tho Person who routinely conducts the monitoring and equipment maintenance under this plan. 490-73. Tfl'LE—Enter the title ol'the pers9n, 490-74. NAME—Enter the name of the second person,if applicable,who routinely conducts the monitoring and equipment maintenance under this plan. 490.75. TITLE—Enter the title of the second person. OWNERJOPERATOR 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 belicves�tbut ull information submitted is true,accurate,and complete,and that the training program specified in Section iX Inas been implemented. ' '- i' 490-76, REPRESENTING —Check the appropriate box to indicate whether the signer is the UST' owner/operator, the UST %cility owner/operator, or an authorized representative of the owner. 490-77. DATE—Enter the dpte the plan was signed. 490-78. APPLICANT N —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)-515 www.unidocs org