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03/16/2009 MON 7: 52 'F'AX 2094693+33 SJC THD 0004/004 (rtgNec) Use(hd)g This plan t ieview0d still: Approval At4wovc4 With C d ions Local AploY Sigrtarure: I>ato: Commonts or Spee)al Conditions: UST Monitoring Plan--Page 2 Instructions Complete a sepnrate UST Monitoring Plan for each UST monitoring system at the facility. This form must be submitted with your initial UST Operating Pennit Application and within 30 days of changes iu the information it contai►►s. Plcase note that your 10041 agency inay rquire you to obtain approval pt for to installing or modifying monitoring equipment. (Note: Numbering of these insu'uctions follows the data element numbers on the form.) 490-54a,MUNITORINU 012'TliF UNL=DISHiNSER CONTAINMENT-Indicalc lite ntetlto0 used Pot UDC nnonitoring. 490-54b.SI'f CIhY-11`99"Other"is checked,describe other method used. If VI-I-I,VI-1-Z or VI-I.3 or VL-1')9 Is checked,oonlplGo 490.55 to 490-64b. 490.55. PANEL M ANU FA(TU IkOk-1201a,the namc of the manulSciurer of the monitoring system control ponul(cons01e). Ville":i$Ito conlrol panel(e.g..only an cletaricai relay box is installed)leave ibis spate blank. 490.56. MODEL A- Enter the modol nurnber for lite monitoring systom control panel(conso)e).If there is no control panel(e.8.,only;III electrical relay box is inslalled)leave this space blank. 490-57, LGAK SENSOR MANUFACTURER-Enter the mine of the manufacturer of rho$onsot(s), 49058. MODEI.q(S)-Enlef rbc model number of[ho soaaor(s)installed.if addilionol spaco is Meted.use Section X. 490.59, I>ti'fF.CTION OF A LEAK INTO THIS UDC TRIGGERS AUDIBLE AND VISUAL ALARMS. hidicala Yes or No 490-60. UAC LEAK ALARM TRIGGERS PUMP SLIUTDOWN- Indicalc Yes or No 490.61. FAILURE/DISCONNECTION OF UDC MONITOniNG SY,STrMN TRIGGERS AUTOMATIC PUMP SI.11.11 )OWN-Indicsic YoR or No 490-62, UDC MONITORING STOPS TME FLAW OF PRODUCT A1"fa1C D1Sl'1;NSI-,It•Indicalc Yes or No. 490.63. UDC CONSTRUCTION- 1110:11e if lite consndclion of lite UDC is Siugle-walled,Of doubtowallcd. 490-646,DUUI)LV WAL 1,ED INTERSTITIAL,SI,ACE MONITORING- Indicate what is used w monllor the interetilial space. 490.64b.LEAK WITHIN TI•Ir SECONDARY CON'1'AIMIiN'1'01'UDC'I'ItIGC ER5 AUDIBLE•AND VISUAL-ALARMS-Indicate Ycs o-No 490.65. VII-1 ELD TFSTINC-Cheek die box it you have boon notifotl by the State Wawr Resourcos Control 0oard(SWRCB)that the UST(s)covered by this plan Were subject to Enhanced Lcak Detection Rcquirerncnls(i.c.t US'f has mty single-wall component and is located within 1,000 feel of a public drinking water well). 490-66. '1 ESfINU OF SECONDARY CONTAINMgKI'COMPONENTS nvartY 36 MONTHS.Cheek rho Dux if you have secondary conlninmont that requires testing. 490.67. SPIV,BIKXM TESTING-Check the box il'you Rave spill buckets. 490.68a.h.Vill RECORDKGCPING-htdicate which monitoring and utuipntent inaintenanco records arc inaitddined for this n+oility. 490-694 IX TRAINING S'I'ATCMCN'1'-Chick the box to verily Ilial the slatenent is lino. 1IGFIi11.12NC13 DOCUMENTS MAINTAINED NI'FACILITY-Cheek ihu apprDVdate boxes to describe roRroneo doownomts maintained at the ntcilily. Note that the lust hvo items on the list Wj;A be kept at the facility. 490-69b. MONITORING PLAN:Indicate that this pian is kept as a reference document. 490-69c, OPEtkKrING MANUALS pOlt ELECTRONIC EQ(fIPMCN'rt Indicate that this plan is kept as a reference doctnncnl. 490-69d. CA VST RCOULATIONS-hndicale that this is kcpl as a reference dDtwncni. 490-69c.CA US1'LAW-indicate that this is kept as a coN-once document. 490-69C STATE WATER RESOURCES CONTROL BOARD(SWRCB)PUBLICATION- "HANDBOOK FOR TANK OWNERS-MANUAL,AND STATISTICAL INVENTORY RECONCILIATION-Indicate,that this is kala as a fefercrim d0cunienl. 490-69g,SWRCB PUBLICATION:"UNDERSTANDING AUTOMATIC TANK GAUGING SYSTEMS":Indicate that This is kept aS a relbrencadoctmicnl. 490.69h.OTWL•R-Indicate that other rclbrone0 documents arm kept. 490.69i. SPL:CIFY-If"O'rllGll"0 chocked,cnla•a bricl"doseripuon of ilio other docuinenl(s)reainwined at the facility.If additional space is needed,see Scolion X. 490-70, 1)I?SlONA'1'ED OPERATOR TRAINING-Check this box to verify that this statement is Luo, 490.71 COMMENTS/ADDITIONAL INFORMATION-Make addilional comments of you may attach and identify the nutnberof additional p3981 of inlbnnaiion to describe any addiiiopol Us'r system monitoring-rolated information(e-g.,additional information required by your local agency). Attach any monitoring logs that you will be using dbr the monitoring of your lank syslcm, 490.72. NAM[:-rimer Ole name of the person wllo routinely conducts the monilo0ig and equipmatt maintenance trader this plan. 490-73. 'TITL.E• Enter the lit lo of the person. 490-74. NAME,-enter the name of Ilio seCond pctson,if applicablo,Who routinely conducts the moniloring and equipment ihaim1e101140 under this plan. 490-75.TITLE'- timer(lie title of the stoond person. OWN(IVOVEItATOR SIGNATUIIG-'['Ile tank owner/opofator,facility nwncr/opaBmr.or an authorized rgxcscnmlive of the own0f 1111311 sign in lite 511300 providM This aignalurocenifes that thesigner believes that all information Submitted is true,accurate,and cornplele,and Ihai lite(raining ptberatn Specified in Section IX baS bean hnplcmented. 490-76. REPRESENTING--Check the opproprialebox to indicota whahor Iha Signa.is 1110 UST ownor/opararor,tltc UST(bodily owne•loperator,or an sudtoriud ropresmiative of the own0i. 490.77. DATI -Enter IhD dale the plan was signed, 49D-78. AI'PI.LCANT NAM 1,-Print Or lype the name of ilio pHoron signing the plan. 490-79. APPLICANT'lTrLL•-Ewer the title of the pas011 signing Iha plan. UPCF UST-D(12/2007)4/4 E 'd tiSLO ON AVLti : 6 60H '1 '13e,