HomeMy WebLinkAbout2015 FMCMONITORING SYSTEM CERTIFICATION
For Use By All Jurisdictions Within the State of CaliforniaAuthority Cited: Chapter 6.7, Health and Safety Code; Chapter 16, Division 3, Title 23, California Code of Regulations
This form must be used to document testing and servicing of monitoring equipment. A separate certification or report must be prepared for each
monitoring system control panel by the technician who performs the work. A copy of this form must be provided to the tank system owner/operator.
The owner/operator must submit a copy of this form to the local agency regulating UST systems within 30 days of test date.
A.General Information
Facility Name:Bldg. No.:
Site Address:City:Zip:
Facility Contact Person: Contact Phone No.:
Make/Model of Monitoring System:Date of Testing/Servicing:
B.Inventory of Equipment Tested/Certified
Check the appropriate boxes to indicate specific equipment inspected/serviced:
Tank ID:Tank ID:
In-Tank Gauging Probe.Model:In-Tank Gauging Probe.Model:
Annular Space or Vault Sensor.Model:Annular Space or Vault Sensor.Model:
Piping Sump / Trench Sensor(s).Model:Piping Sump / Trench Sensor(s).Model:
Fill Sump Sensor(s).Model:Fill Sump Sensor(s).Model:
Mechanical Line Leak Detector.Model:Mechanical Line Leak Detector.Model:
Electronic Line Leak Detector.Model:Electronic LineLeak Detector.Model:
Tank Overfill / High-Level Sensor.Model:Tank Overfill / High-Level Sensor.Model:
Other (specify equipment type and model in Section E on Page 2).Other (specify equipment type and model in Section E on Page 2).
Tank ID:Tank ID:
In-Tank Gauging Probe.Model:In-Tank Gauging Probe.Model:
Annular Space or Vault Sensor.Model:Annular Space or Vault Sensor.Model:
Piping Sump / TrenchSensor(s).Model:Piping Sump / Trench Sensor(s).Model:
Fill Sump Sensor(s).Model:Fill Sump Sensor(s).Model:
Mechanical Line Leak Detector.Model:Mechanical Line Leak Detector.Model:
Electronic Line Leak Detector.Model:Electronic Line Leak Detector.Model:
Tank Overfill / High-Level Sensor.Model:Tank Overfill / High-Level Sensor.Model:
Other (specify equipment type and model in Section E on Page 2).Other (specify equipment type and model in Section E on Page 2).
Dispenser ID:Dispenser ID:
Dispenser Containment Sensor(s).Model:Dispenser Containment Sensor(s).Model:
Shear Valve(s).Shear Valve(s).
Dispenser Containment Float(s) and Chain(s).Dispenser Containment Float(s) and Chain(s).
Dispenser ID:Dispenser ID:
Dispenser Containment Sensor(s).Model:Dispenser Containment Sensor(s).Model:
Shear Valve(s).Shear Valve(s).
Dispenser Containment Float(s) and Chain(s).Dispenser Containment Float(s) and Chain(s).
Dispenser ID:Dispenser ID:
Dispenser Containment Sensor(s).Model:Dispenser Containment Sensor(s).Model:
Shear Valve(s).Shear Valve(s).
Dispenser Containment Float(s) and Chain(s).Dispenser Containment Float(s) and Chain(s).
*If the facility contains more tanks or dispensers, copy this form. Include information for every tank and dispenser at the facility.
C.Certification -I certify that the equipment identified in this document was inspected/serviced in accordance with the manufacturers’
guidelines. Attached to this Certification is information (e.g. manufacturers' checklists)necessary to verify that this information is
correct and a Plot Plan showing the layout of monitoring equipment. For any equipment capable of generating such reports, I have also
attached a copy of the report;(check all that apply):System set-up Alarm history report
Technician Name (print):Signature:
Certification No.:License. No.:804904
Testing Company Name:Confidence UST Services, Inc.Phone No.:(800)339-9930
Site Address:Date of Testing/Servicing:
Page 1 of 3
#3351Howard's#4
3200PanamaLane Bakersfield93313
OmeroGarcia (661)393-7000
Veeder-RootTLS-350 10/07/2015
12,000gal.Regular1
847390-107
WPLLD
847390-107
12,000gal.Regular2
847390-107
WPLLD
847390-107
12,000gal.Super
847390-107
WPLLD
847390-107
12,000gal.Diesel
847390-107
WPLLD
847390-107
1-2
794380-208/001
3-4
794380-208/001
5-6
794380-208/001 794380-208/001
Bradley Seykora
B45438
3200PanamaLane Bakersfield,CA93313 10/07/2015
794380-208/001
794380-208/001
Monitoring System Certification
D.Results of Testing/Servicing
Software Version Installed:
Complete the following checklist:
Yes No*Isthe audible alarm operational?
Yes No*Is the visual alarm operational?
Yes No*Were all sensors visually inspected, functionally tested, and confirmed operational?
Yes No*Were all sensors installed at lowest point of secondary containment and positioned so that other equipment will
not interfere with their proper operation?
Yes No*
N/A
If alarms are relayed to a remote monitoring station, is all communications equipment (e.g., modem)
operational?
Yes No*
N/A
For pressurized piping systems, does the turbine automatically shut down if the piping secondary containment
monitoring system detects a leak, fails to operate, or is electrically disconnected? If yes: which sensors initiate
positive shut-down? (Check all that apply) Sump/Trench Sensors; Dispenser Containment Sensors.
Did you confirm positive shut-down due to leaks and sensor failure/disconnection? Yes; No.
Yes No*
N/A
For tank systems that utilize the monitoring system as the primary tank overfill warning device (i.e., no
mechanical overfill prevention valve is installed), is the overfill warning alarm visible and audible at the tank
fill point(s) and operating properly? If so, at what percent oftank capacity does the alarm trigger? %
Yes*NoWas any monitoring equipment replaced? If yes, identify specific sensors, probes, or other equipment replaced
and list the manufacturer name and model for all replacement parts in Section E, below.
Yes*NoWas liquid found inside any secondary containment systems designed as dry systems? (Check all that apply)
Product; Water. If yes, describe causes in Section E, below.
Yes No*Was monitoring system set-up reviewed to ensure proper settings? Attach set up reports, if applicable
Yes No*Is all monitoring equipment operational per manufacturer’s specifications?
* In Section E below, describe how and when these deficiencies were or will be corrected.
E.Comments:
Page 2 of 3
327.04
90
Only the dispenser sensors were tested due to repairs made. All dispenser 208 and 001 sensors were confirmed operational.