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0 (Agency Use Only) This plan has been reviewed and: ❑Approved ❑Approved With Conditions ❑Disapproved Local Agency Signature: Date: Comments or Special Conditions: UPCF UST Monitoring Pian — 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 prior,to installing or modifying monitoring equipinent.. (Note: Numbering of these instructions follows the data element numbers on the form.) 490-54a. MONIIORING 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-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 DEIECTION 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. 490-6I FAILURE/DISCONNECTION OF UDC MONITORING SYSTEM TRIGGERS AUTOMATIC PUMP SHUTDOWN-Indicate Yes or No. 490-62 UDC MONITORING STOPS IHE FLOW OF PRODUCT AT THE DISPENSER-Indicate Yes or No 490-63, UDC CONSTRUCTION-Indicate if the construction ofthe UDC is single-wailed,or double-walled. 490-64a DOUBLE-WALLED INTERS TIT IAL SPACE MONI TORING-Indicate what is used to monitor the interstitial space 490-64b.LEAK WITHIN THE SECONDARY CONIAINMENT 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 USI(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. TESTING OF SECONDARY CONTAINMENT COMPONENTS EVERY 36 MONTHS-Check the box if you have secondary containment that requires testing. 490-67 SPILL BUCKET TESTING-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 S TATEMENT-Check the box to verify that the statement is true. REFERENCE DOCUMENTS MAINTAINED 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 OPERAIING MANUALS FOR ELECTRONIC EQUIPMENT:Indicate that this plan is kept as a reference document. 490-69d. CA UST REGULAIIONS-Indicate that this is kept as a reference document. 490-69e CA UST LAW-Indicate that this is kept as a reference document 490-69f STATE WATER RESOURCES CONTROL BOARD(SWRCB)PUBLICATION- "HANDBOOK FOR IANK OWNERS-MANUAL AND STATISTICAL INVENTORY RECONCILIATION":Indicate that this is kept as a reference document 490-69g.SWRCB PUBLICAIION:"UNDERSTANDING AUTOMATIC TANK GAUGING SYSIEMS":Indicate that this is kept as a reference document 490-69h.OTHER-Indicate that other reference documents are kept 490-69i SPECIFY-If'OT HER"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 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,if'applicable,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 ownedoperator,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 DATE-Enter the date the plan was signed, 490-78. APPLICANT 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.unidocs.org