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03l-09/2010 14:34 12099432961- CHP STOCKTON PAGE 09/15
<br /> (Agengv Use Only) This pian has boon laced d: pproved ❑Approved With Conditions ❑Disapproved
<br /> Local Agency Signature: Date: 114rC_L-
<br /> Comments or Special Conditions;
<br /> CF UST Monitoring Plan —Page 2 Instructions
<br /> Complete a separate UST Monitoring Plan for each UST monitoring system at the facility, This form must be submitted with your initial UST
<br /> Operating Permit Application and within 30 days of changes in the information it contains. Please note that your local agency may require you to
<br /> obtain approval 2E Lor to installing or modifying monitoring equipment, (Note; Numbering of these instructions follows the data element numbers on
<br /> the form.)
<br /> 490-54a- MONITORING OF THE UNDER DISPENSER CONTAINMENT.indicate the method used for UDC monitoring.
<br /> 490-54b. SPECIFY if 99"Other'is checked,describe other method used.
<br /> If vl-1-i,VI-1-2 or VI-1-3 or VI.1.99 is checked,complete 490.55 to 490.646.
<br /> 490-55, PANEL MANUFACTURER-Enter the name of the manufacturer of the monitoring system control pool(console). If there is no control panel(e,g„only an electrical
<br /> relay box is installed)leave this spocc blank.
<br /> 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
<br /> this space blank,
<br /> 490.57. 1•EAK SENSOR MANUFACTURFIk Enter the name of the manufacturer of the sensor(s).
<br /> 490-58. MODEL#(S)-Enter the model number of the scnsor(s)installed.If additional space is needed,use Section X.
<br /> 490.59, DETECTION OF A LEAK INTO THE UDC TRIGGERS AUDIBLE AND ViSUAL ALARMS. indicate Yes er No.
<br /> 490.60. UDC LEAK ALARM TRIGGERS PUMP SHUTDOWN-Indicate Yes or No.
<br /> 490.61, FAILURE-015CONNECTION OF UDC MONITORING SYSTEM TRIGGERS AUTOMATIC PUMP SHUTDOWN-Indicate Yes or No.
<br /> 490.62. UDC MONITORING STOPS THE FLOW OF PRODUCT AT THE DISPENSER-Indicate Yes or No.
<br /> 490-63. IJDC CONSTRUCTION Indicate if the construction of the UDC is single-walled,or double-wailed.
<br /> 490-64a. DO1181..13-W ALLUD INTERSTITIAL SPACE MONITORING-Indicate what is used to monitor the interstitial space,
<br /> 490-64h. LL;AK WiTHiN THE SECONDARY CONTAINMENT OF UDC TRIGGERS AUDIBLE AND ViSUAL ALARMS-indicate Yes or No,
<br /> 490-65, VIi-i F.LD T13STING-Check the box if you have been notified by the State Water Resources Control Board(SWRCB)that the UST(s)covered by this plan is/are
<br /> subject to Enhanced Leak Detection Requirements(i.e.,UST has any singic-wall component and is located within 1,000 feet of a public drinking water well).
<br /> 490-66. TESTING OF SECONDARY CONTAINMENT COMPONiwNTS EVERY 36 MONTHS-Check the box if you have secondary containment that regvires testing.
<br /> 490-67. SPILL BUCKET TESTING-Cheek the box if you have spill buckets.
<br /> 490-M, Viil RECORDKFF''PiNG-Indicate which monitoring and oquiptnent maintenance records arc maintained for this facility,
<br /> 490-69a, IX TRAINING STATEMENT-Check the box to verify that the statement is true,
<br /> RVERENCE DOCUMENTS MAINTAINED AT FACILITY-Check the appropriate boxes to describe reference documents maintained at the facility. Note that the
<br /> first two items on the list must be kept at the facility.
<br /> 49M9b,MONITORING PLAN:indicate that this plan is kept as a reference document
<br /> 490.69c. OPERATING MANUALS FOR ELECTRONIC EQUIPMENT:Indicate that this plan is kept as a reference doeuncnt
<br /> 490-69d, CA UST REGULATIONS-Indicate that us is kept as a reference document,
<br /> 490-69c. CA LIST LAW•-indicate that this is kept as a reference document,
<br /> 490-69f. STATE WATER RESOURCES CONTROL BOARD(SWRCB)PUELICATiON- "HANDBOOK FOR TANK OWNERS-MANUAL ARID
<br /> STATISTICAL INVENTORY RECONCILiATiON"!Indicate that this is kept as a reference document.
<br /> 490-69g.SWRCB PUBLICATION:"UNDERSTANDING AUTOMATIC TANK GAUGING SYSTEMS";indicate that this is kept as a reference document,
<br /> 490-69h,OTHER-Indicate that other referent:documents are kept.
<br /> 490-69i, SPECIFY• Ir"OTHER"is checked,enter a brief description of the other docum*nl(s)maintained at the facility.If additional space is needed,sec Section X.
<br /> 490-70, DESIGNATED OPERATOR TRAINING-Check this box to verify that this statement is true,
<br /> 490.71. COMMENTS/ADDiT10NAL INFORMATION-Make additional comments or you may attach and identify the number of additional pages of information to describe
<br /> any additional LiST system monitoring-related information(e.g.,additional information required by your local agency). Attach any monitoring logs that you will be
<br /> using for the monitoring of your tank system
<br /> 490.72. NAME Enter the name of the person who routinely conducts the monitoring and equipment maintenance under this plan,
<br /> 490-73. TITLE-Enter the title of the person.
<br /> 490-74, NAM$-Enter the name of the second person,if applicable,who routinely conducts the monitoring and equipment maintenance under this plan.
<br /> 490-75. TITLE-Enter the title or the second person.
<br /> OWNERIOPERATOR SIGNATURE..-The tank owner/operator,facility owner/operator,or an authorized representative of the owwr shall sign in the space provided.
<br /> This signature cenifres that the signer believes that all information submitted is true,accurate,and complete,and that the training program specified in Section IX has
<br /> been implemented.
<br /> 490-76. REPRESENTING •- Check the appropriate box to indicate whether the signor is the UST owner/operator, the UST Facility nwner/operator, or an authorized
<br /> representative of the owner.
<br /> 490-77. DATE-Enter the data the pian was signed,
<br /> 49D-78. APPLICANT NAME- Print or type the name of the person signing the plan.
<br /> 490.79, APPLICANT TITLE-Enter the title of the person signing the plan.
<br /> LIPC'F UST-I)(12/2007)-4/4 www.unidocs.org
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