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i (Agency Use Only) This plan has been reviewed and: 10 Approved ❑Approved With Conditions El Disapproved ' 1 Local Agency Signature: 6) � ' k Date: ��/I Comments or Special Conditions: UPCF UST Monitoring Plan—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 equipment. (Note: Numbering of these instructions follows the data element numbers on the form.) G41ONT-TORIP16—C . 490-54a.MONITORING OF THE UNDER DISPENSER CONTAINMENT-Indicate the methal used for UDC monitoring AD(S) CIto& he appropriate-boxies)-to-ideWi€y-all requiRd methods used tent 490-54a-I-i€!he by a-leak sonsoF eenneeted to a eentiamous monitoring eonsele with aadibl a-2 if-the meehan goal devise that shuts the dispenser's ShOaF YRIVO lifts a leak detee-fien fl-eat.Ch.em k_it-a-rA 490 5 4a 3 if the UDG is monito-ed by a stand a10418 i8ak SeRSOF that is ROt 09RA6010d t@ R GOR Donsele.4ne d4speas am installed(e.g.,emeFgenoy go alar-tanl�systenij 490-54b.SPECIFY-If 99"Other"is checked,describe other method used. SPECIFY if item 490 3 ptien-ef4h other-UDG Mon itoring-method(s)-usad—l€tta 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. "fh0t trer-O€the tisele). 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 blankA40DE6# lFitern49054alisehooked'eat—the med-I number fbF the monitoring wfiiera aenifel panel. 490-57. LEAK SENSOR MANUFACTURER-Enter the name of the manufacturer of the sensor(s).LEAK SPISOR NGOWFACTURER If item 490 54a 1 OF 490 54a �aante- fhetnanafaetUFOFOfth '.Sfladuse Seutien X. 490-58. MODEL#(S)-Enter the model number of the sensor(s)installed.If additional space is needed,use Section X. eh W4he4nod"umbe F installed.1AM-Ore spaeo-is n X. 490-59. DETECTION OF A LEAK INTO THE UDC TRIGGERS AUDIBLE AND VISUAL ALARMS. Indicate Yes or No.Wl r DETE TION OF A LEAK DITO T149 490-60. UDC LEAK ALARM TRIGGERS PUMP SHUTDOWN-Indicate Yes or No.WIL6 UPC LEAK ALARM TRIGGER PbJMP SHUT-DONWO Cheek Yes of NO: 490-61. FAILURE/DISCONNECTION OF UDC MONITORING SYSTEM TRIGGERS AUTOMATIC PUMP SHUTDOWN - Indicate Yes or No.W111 i 140. 490-62. UDC MONITORING STOPS THE FLOW OF PRODUCT AT THE DISPENSER-Indicate Yes or No. FLOW OF PRODUCT AT T-149 DISPENSER UPON LEAK OB4NGTION? GheekVese 490-63. UDC CONSTRUCTION-Indicate if the construction of the UDC is single-walled,or double-walled.UDG CONSTRUCTICN C-11016 010 RpprOpFiate box to indieate lullethOf thO UDG has Single Wall OF double wall construction.if you eheak item 490 63 1,sleip to Seetion VII. 490-64a. DOUBLE-WALLED INTERSTITIAL SPACE MONITORING-Indicate what is used to monitor the interstitial space.UDG lNTERSTITIAL SPAGS 19 if yett cheek item 490 63 2,eheale the appfopFfato box to eserib*th eniterirtg provided ndary eentainnient- 490-64b.LEAK WITHIN THE SECONDARY CONTAINMENT OF UDC TRIGGERS AUDIBLE AND VISUAL ALARMS-Indicate Yes or No.WILL DETECTIGN-AF-A LEAK Pi THE UDG INTERSTITLkL SPACE TRIGGERAUDE3LB M%M VISUAL ALARMS? ifyouehookitm490632,eh@Gle3loser�le. V111.PERIODIC 8V-ST-R-All TESTING 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 istare subject to Enhanced Leak Detection Requirements(i.e.,UST has any single-wall component and is located within 1,000 feet of a public drinking water well).EW FEST"a..NG--Cheek-this-bet-if- w,SWR4CB4ias-notified-ru4imt-you-ntttst per€e n(E D) V-su de not.. box ifyou need to peFferm one time 6bg testing(e.g.,past iAstallmiffl teSILW 490-66. TESTING OF SECONDARY CONTAINMENT COMPONENTS EVERY 36 MONTHS - Check the box if you have secondary containment that requires testingSECON DARX GONTAINMFNT TEST-DIG You must eheak this beq and pFevide Pffiedie testing if you have any UST systef" seeond 490-67. SPILL BUCKET TESTING-Check the box if you have spill buckets.SPILL BUCKET-E T NG-4e a annuakesting-ef -ttll UST fill spill buckets: VIII.RECORD KEEPING 490-68. VIII RECORDKEEPING - Indicate which monitoring and equipment maintenance records are maintained for this facility.MON 1TORIN&MAINTENANCE nEGG rm-h IX.TRtII qNG 490-69a. IX TRAINING STATEMENT--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.Cheek-the with relevant re ee desuments Cheek the app repriaie boxes f6F itSMS 490 69b thfaugh It to ' ent'reference doetunents that are maintained at the €acility-Note that ter)` 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. 490-69e. CA UST LAW-Indicate that this is kept as a reference document. 490-69£ 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.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. UPCF UST-D(12/2007)-5/6 www.unidocs.org