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Alk (Agency 1JW Only) This plan has been r ievve ow- Approved ®Approved With Conditiot Local Agency Sipaturc— Commerair or Special C;ond tions U T 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 appro`alrior to installing or modifying monitoring equipment, (Nett;: Numbering of these instructions follows the data element numbers on the form.) 4411.54a.MONITORING OF THE UNDER DISPENSER CONTAINMENT-Indicate the method used for UDC monitoring. 490-54b.SPECIFY-11799"Other"is checked,describe other method used. If V1-1-1,VI-I-2 or VI-1-3 or VI-i-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), Ifthcrc is no control panel(irg.,only an electrical relay baa is installed)leave this space blank. 490-56 MODEL 4- 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. 4190-57. LEAK SENSOR MANUFACT€REL,...f3mer the name of the manufacturer of the sensoite}. 490-58. MODEL 4(S)-.Enter the model number of the sensor(s)installed.If additional spade is needed,use Section X. 440-59, DETECTION OF A LEAK INTO THE UDC TRIGGERS AUDIBLE AND VISUAL ALARMS Iridicate Yes or'No 490-60 UDC LEAK ALARM TRIGGERS PUMP SHUTDOWN Indicate Yes or No 4411-61, FAILURE 4_ASCONNECTION OF LIM. MONITORING SYSTEM TRIGGERS AUTOMATIC PUMP SHUTDOWN-Indicate Yes or No 4W-62. UDC IMONITORING STOPS THE FLOW OF PRODUCT AT THF,DISPENSER-Indicate Yes or tato. 490-63. 1_= CONSi'RUC`rION- Indicate if the construction or the UDC is single-ivralled,or double=walled, 490-04a.DOUISLE-WA LEDINTERSTIT'IAL SPACE MONITORING- Indicate what is used to monitor theinterstitial space, 4961-64b,LEAK WITHIN THE SECONDARY CONTAIMENT OF UIX TRIGGERS AUDIBLE AND VISUAL ALARMS-Indicate Yes or No 490-65. VII-I ELI7'I`ESTING-Check the box if you have been notified by the State Water Resources Control Board(SWRCl3)that the UST(s)covered by this plan istare subject to Enhanced Leah Detection Requirements(i e.,UST has any single-wall component and is located within 1,000 feet of a public drinking water well). 190.66, TFSTING OF SECONDARY CONTAINMENT COMPONENTS EVERY 36 MONTHS-Check the box ifyou have secondary containment that requires testing. 490-67. SPILL BUCKET TESTING-Check the box if you have spill buckets. 490-68a-h.Vill RE CORDKEF PING-Indicate which monitoring and equipment maintenance records are maintained for this facility, 490-69a IX TRAINING STATEMENT-EMENT-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 rqgg be kept at the facility. 490-69b. MONITORING PLAN:Indicate that this}flan is kept as a reference document. 490-64c OPERATING MANUALS FOR ELECTRONIC(EQUIPMENT,Indicate that this plan is kept as a referee document_ 440-69d. CA UST REGULATIONS-Indicate that this is kept as a reference document. 4915-69e. CA UST LAW-indicate that this is kept as a reference document. 490-69f STATE WA'1 F'R RESOURCES CONTROL 130ARD CSW R(.,B)PUBLICATION- HANDBOOK FOR TANK OWNERS-MANUAL AND STATISTICAL INVE?NTORY RECONCILIATION-ludicate trial this is kept as a reference document. 490-69g.SWRCB PUBLICATION:"LIN DERSTAN DING fAU TOMATIC"TANK.GAU61NO SYSTEMS":Indicate that this is kept as a reference document. 490-69h.OTHER-€ndicaic that other reference documents are kept. 490-69i. SPECIFY-Ii'"OTHER"is checked,enter a brie£description of the other document(s)maintained at the facility.Ifadditional space is needed,see Section X. 440-70. DESIGNATED OPERATOR TRAINING Check this box to verify that this statement is true. 490-7I. COMMENTs,'ADDrnoNAL_INFORMATION—Make additional comments orvou may attach and identity the number of additional pages of information to describe any additional UST system monitoring-related information(e,&,additional information required by your local agency), Attach any monitoring logs that you will be easing 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 ofthe second person. OWNERJOPERATOR SIGNATURE- The tank oawnevoperator,facility ownerloperator,or an authorized representative of the owner shall sign in the space provided, This signature certifies that the signer believes that all infonttation 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 oawnevoperator,or an authorized representative of the owner. 490.77. DATE--Enter the date the plan eras signed, 490-78 APPLICANTNAME_.Print or type the name of the person signing the plan. 490-79. APPLICANT TITLE—Enter the title of the person stgmng the plan. UPCF UST-D(11=2007)4/4