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<br /> (Amey(Ise Only) Thi5 plan has been reviewed and: C]Approvied El Approved With Conditions rl Disapproved
<br /> Local Agency Signature' Date:
<br /> Comments orSpecial Conditions:
<br /> UPCF UST Monitoring Plan—Page 2 Instructions
<br /> Complete a separatic UST Monitoring Plan for cacti UST monitoring systein at the facility, Thi:; lbirm must be subinittud with your initial u.sr
<br /> Operating Ilennit Application and.within 30 days ol'chang4us ill Lilt; 411`011jalion it contains. note that your local agency muy require you to
<br /> obtain approval prior to installing or rnotlifying nio0oring equipment. (Note: Numbering of these instructions follows the data elciricrit numbers on
<br /> the form.)
<br /> 490-54a. MONITORING OF Tl IF UNDER 1>I,9PF,NSr;R(7.()NTAtNMENTIn(jitzale lhe inctliott tsed fort.[DC immituring,
<br /> 4%-54b. SPECIFY-If 91)-I.Illicr-is checked,describe other method w".
<br /> If VI-1-1,VI-I 1 or VI-1-3 or VI-1-99 is chl-ekcil,complete 4!)0-55 to 490-641)
<br /> 4L00-59, PANE!,MANI&M.I'LlAk2,11 Enter tho m....cycle rnwwfiwturer tf it". .k il"fine'L.Von.111 4-.vilirrill panel(Cillwo ILI 1. irthere i5nocontrol paTtet(o.v.,,only anelectrical
<br /> relay be,;is initialled)leave this spit"blank.
<br /> 490_16r MOL)E'l 11 linter the model number Ikir lite wonitoring system control liant:1(COMOIC).lifthere is no control panel(e.g.,only alt electrical relay box is installed)leave
<br /> this space blank.
<br /> AQ6-17 IFAK SIFINISOR MANUFACTURER Faitor the zinnic of the inanuflicturcr ol'thu
<br /> 490-58. MODF14(S) Enter lite totillo ntirnlicr of the sensor(q)intaislictl.lNulditional space is needed,meScClion X.
<br /> 490-59. DuEcTiON UFA I.IiAK JNTOTHE UL)CTRIC(MRS AUDIBLE AND V(SLIAI.AI.ARMS. Indicate Yes or No.
<br /> 490-60. UDC H`AK AI.AftMTRKj0FRS PUMP NJ it TI IX)WN -Indicate Yes or No
<br /> 400.61, 1;All A tit v/rii.-r.r)NNj:.(7ri0N 01;In X-MONITORING SYS-1-1(M FRI(i0l"RS AUTOMA,ric PUMP.';]11 Tl'[X)WN--Indicate Yes or No.
<br /> 490-62. 1 IDC MONITORING STQP",'I'I W PLOW OF PRODU(.71 ATTI IE DISPENSER-indicalt..Yes or No.
<br /> 490-63. 0TjC CONSTRUCTION Indielile if the construction 0`1114;UDC is single-walled,or double-trilled.
<br /> 4Wj-64a, DOUBLE-WA11T,l)INI'l4l(SlITIAL SPACE MONITORIN6 Initicattwhat is used tt)mc)itilc)rthe interstitial space.
<br /> 400 Nib, LEAK WITT IIN'l I-IF IWCONIUR V VONTAiNMEN1 OF UDC CRIGGERS AUD1111.1 AND VISIjAi.ALARMS-Indicato Yes or No.
<br /> 490-65, VIII 1(1-1) I'hS`J'IN0-Check the box W yotj gave been notified by Jim Slislu Witter Resources Control Board(S"Cll)iluit ific LIST(s)covered by this plan Ware
<br /> 50*1 to Enhanced I.cak Detection Rt:qttiM.THeni%(i L!.,I IS I'W any single-will minlyontan and is Located within 1,000 Rxil ol'a public drinking water well).
<br /> 490.66, 'TT1,sTI N(i OF SECONDARY CONI*A I NMI;NJ'('0M PONRNTS EVERY 36 MONI'l I$ Check the box i r you have secondary containincra that requires testing.
<br /> 440_67 spii.i,micurTESTING-(:heek the box if volt have spill butActs.
<br /> 490-68, V111RECORDKEEPINQ I ndicale which nyinitoring and equipment nutinieliance;records RTC Alai"tilined I)l r 1111%1ILL-11 it V,
<br /> 490-6(;;11. IXTRAINING STATF.mrNY ('leek the box to verify that IN;,aalcnilait iS true.
<br /> REFERENCE D(X:.UMI;N'I*$MAINTAINED AT FACILITY (1eck the appropriate boxes to describe it1krence doettrucrin maintained at the Ilicilily. Note that the
<br /> first two items on the list rinflit be keel at the faCilitV.
<br /> 490-69b. MONITORING PLAN:Indicate that this likin is kept as a reference documovi,
<br /> 490.69e ()PI.,,RA I-ING MANUALS FOR ELLCI-RUNIC IiQI HPMENT:Indicate that Illis plata b;kept as a reference document,
<br /> 490.69d.CA USTRE(JUI.NHONS-Indicate that this is kup(ii-;a teference docurnent.
<br /> 4410-60e.VA I INT LAW -bulicalt:tMi IN,.is kept a.,a reference dmurnent.
<br /> 490-69f, STATE WATER RESOURCES CONTROL BOARD(SWRCB)PUBLICATION 11ANDBOOKFOR-IANKOWNERS MANUAL AND
<br /> STATISTIC.A(.INVENTORY RECONCILIATION" indicate that this is kept as it wrcruice docunicK
<br /> 490-69g.SWRCB Pt B1,1CATION:"UNDERS1 ANDING Al ITOMA,ricTANK(;Ak)GING SYSTEMS":Indicate that this is kept as a mfoence docurrient
<br /> 400-696.CA'HER kept.
<br /> 490�19i. SPECIFY - Jt0TIIJW' the 11wility.Ifaciditionalspace is caned,see$eciion X.
<br /> 490-70. DESIGNATI",J)OPERATORTRAINING.-Check this box to verify that this statement is true.
<br /> 4()0-71. COMML;tVI*S/AI)1)1'1'10NAI.lNrORMATION Make ilddilional coninients or you may atUichwid identify the number cifadditional j*gr_%ofinforrrtationtodmriW
<br /> any additional UST uyow-invnilotinA-related information add;iies"I inrnmintinn required by your Local aucticy). Attach any monitoring too dirt You will be
<br /> Using for the Monitoring(Ify0tir lank NyNicni
<br /> 490-77.. NAME--Enter the lionle of ilio l7mon wilt?i otaincly eonducts the inoniloring and vquipsuont rrlainteiinnc,e under this plan.
<br /> 490-73. *171'I'Ll," 1(Alec the title of the perwri.
<br /> 490 74. NANIU 161tae'tie name ofthe szecond pers;4.0*-,,J%jNli&qIih,.whn rniffinnly voiulori-;tlar inonitornig ind alailKneril rnaintertime tinder 0n$plan.
<br /> 490-75 TITI-F I;Iilcttaw title ofthe second person.
<br /> QWNFR/O('KftATOR SIGNATURE The tank owner/operator,facility ONVM-CloWisikw,or an authorized representative of the owner shall sign inthe space provided.
<br /> This signature ucitifici illitt the signer believes that;ill inibritifflion.itibinJued is true,acs wunite,and complete,and that the training program%pecified in Section IX has
<br /> been implemented.
<br /> 4-A)-'16 RrrRF3rl,,rrIN(; c7il-1, lite iq)pr,)jlrkkW box it, i:; the U%T it facility riwitarloperator, or an autho0yod
<br /> reprowninjive offlic owner.
<br /> 490-77. DATI;..tinter the date the plan ww;signed.
<br /> 490-78, APPLICANT NAME Print or ly;w.Hit:name of the person signing the plain
<br /> 490-79, APPLICAN'ri,nix I(nies I lie rule of the person signing the plan.
<br /> VPCFIJ,5T.D(I2/2(107)-4/4 www.unidoes.org
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