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Home My WebLink About FMC 2015 2/21/07 1 Appendix VI (Copies of Monitoring System Certification form and UST Monitoring Plot Plan available at http://www.waterboards.ca.gov.) MONITORING SYSTEM CERTIFICATION For Use By All Jurisdictions Within the State of California Authority 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: ____________________________________________ In-Tank Gauging Probe. Model: ____________________ Annular Space or Vault Sensor. Model: ____________________ Piping Sump / Trench Sensor(s). Model: ____________________ Fill Sump Sensor(s). Model: ____________________ Mechanical Line Leak Detector. Model: ____________________ Electronic Line Leak Detector. Model: ____________________ Tank Overfill / High-Level Sensor. Model: ____________________ Other (specify equipment type and model in Section E on Page 2). Tank ID: ____________________________________________ In-Tank Gauging Probe. Model: ____________________ Annular Space or Vault Sensor. Model: ____________________ Piping Sump / Trench Sensor(s). Model: ____________________ Fill Sump Sensor(s). Model: ____________________ Mechanical Line Leak Detector. Model: ____________________ Electronic Line Leak Detector. Model: ____________________ Tank Overfill / High-Level Sensor. Model: ____________________ Other (specify equipment type and model in Section E on Page 2). Tank ID: ____________________________________________ In-Tank Gauging Probe. Model: ____________________ Annular Space or Vault Sensor. Model: ____________________ Piping Sump / Trench Sensor(s). Model: ____________________ Fill Sump Sensor(s). Model: ____________________ Mechanical Line Leak Detector. Model: ____________________ Electronic Line Leak Detector. Model: ____________________ Tank Overfill / High-Level Sensor. Model: ____________________ Other (specify equipment type and model in Section E on Page 2). Tank ID: ____________________________________________ In-Tank Gauging Probe. Model: ____________________ Annular Space or Vault Sensor. Model: ____________________ Piping Sump / Trench Sensor(s). Model: ____________________ Fill Sump Sensor(s). Model: ____________________ Mechanical Line Leak Detector. Model: ____________________ Electronic Line Leak Detector. Model: ____________________ Tank Overfill / High-Level Sensor. Model: ____________________ Other (specify equipment type and model in Section E on Page 2). Dispenser ID: ________________________________________ Dispenser Containment Sensor(s). Model: ____________________ Shear Valve(s). Dispenser Containment Float(s) and Chain(s). Dispenser ID: ________________________________________ Dispenser Containment Sensor(s). Model: ____________________ Shear Valve(s). Dispenser Containment Float(s) and Chain(s). Dispenser ID: ________________________________________ Dispenser Containment Sensor(s). Model: ____________________ Shear Valve(s). Dispenser Containment Float(s) and Chain(s). Dispenser ID: ________________________________________ Dispenser Containment Sensor(s). Model: ____________________ Shear Valve(s). Dispenser Containment Float(s) and Chain(s). Dispenser ID: ________________________________________ Dispenser Containment Sensor(s). Model: ____________________ Shear Valve(s). Dispenser Containment Float(s) and Chain(s Dispenser ID: ________________________________________ Dispenser Containment Sensor(s). Model: ____________________ Shear Valve(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.: ________________________________________ Testing Company Name: _______________________________________________ Phone No.:(_______)_____________________________ Testing Company Address: ___________________________________________________________ Date of Testing/Servicing: ____/____/_____________ Monitoring System Certification Page 1 of 4 12/07 CK2701270 5634STINERD BAKERSFIELD,CA 93313 TONYAPICENO 661-834-8625 VEEDERROOT/TLS-350 12/10/15 UNL-REG UNL-PREM ✔ ✔ MAG-1 ✔MAG-1 ✔ 794390-409 ✔794390-409 794380-208 ✔794380-208 ✔LD-2000 ✔LD-2000 ✔DROPTUBEW/FLAPPER ✔DROPTUBEW/FLAPPER 1/2 3/4 ✔✔ ✔✔ 5/6 7/8 ✔ ✔ ✔ ✔ ✔✔ RICKGRIFFITH Rick Griffith Digitally signed by Rick Griffith DN: cn=Rick Griffith, o=IDECO Inc., ou, email=griffithdaddy@gmail.com, c=US Date: 2015.12.10 13:21:30 -08'00' B41503 744619 IDECOInc.818 452-9931 7306ColdwaterCyn.STE7,NorthHollywood,CA91605 12/10/15 2/21/07 2 D. Results of Testing/Servicing Software Version Installed: _____________________________________ Complete the following checklist: Yes No* Is the 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 of tank capacity does the alarm trigger? ________% Yes* No Was 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* No Was 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: ___________________________________________________________________________________________ __________________________________________________________________________________________________________ __________________________________________________________________________________________________________ __________________________________________________________________________________________________________ __________________________________________________________________________________________________________ _________________________________________________________________________________________________________ __________________________________________________________________________________________________________ __________________________________________________________________________________________________________ __________________________________________________________________________________________________________ __________________________________________________________________________________________________________ __________________________________________________________________________________________________________ _________________________________________________________________________________________________________ __________________________________________________________________________________________________________ __________________________________________________________________________________________________________ __________________________________________________________________________________________________________ __________________________________________________________________________________________________________ __________________________________________________________________________________________________________ __________________________________________________________________________________________________________ Monitoring System Certification Page 2 of 4 12/07 ✔ ✔ ✔ ✔ ✔ ✔ ✔ ✔ ✔ ✔ ✔ 328.03 ✔ ✔ ✔ 2/21/07 3 F. In-Tank Gauging / SIR Equipment: Check this box if tank gauging is used only for inventory control. Check this box if no tank gauging or SIR equipment is installed. This section must be completed if in-tank gauging equipment is used to perform leak detection monitoring. Complete the following checklist: Yes No* Has all input wiring been inspected for proper entry and termination, including testing for ground faults? Yes No* Were all tank gauging probes visually inspected for damage and residue buildup? Yes No* Was accuracy of system product level readings tested? Yes No* Was accuracy of system water level readings tested? Yes No* Were all probes reinstalled properly? Yes No* Were all items on the equipment manufacturer’s maintenance checklist completed? * In the Section H, below, describe how and when these deficiencies were or will be corrected. G. Line Leak Detectors (LLD): Check this box if LLDs are not installed. Complete the following checklist: Yes No* N/A For equipment start-up or annual equipment certification, was a leak simulated to verify LLD performance? (Check all that apply) Simulated leak rate: 3 g.p.h.; 0.1 g.p.h ; 0.2 g.p.h. Yes No* Were all LLDs confirmed operational and accurate within regulatory requirements? Yes No* Was the testing apparatus properly calibrated? Yes No* N/A For mechanical LLDs, does the LLD restrict product flow if it detects a leak? Yes No* N/A For electronic LLDs, does the turbine automatically shut off if the LLD detects a leak? Yes No* N/A For electronic LLDs, does the turbine automatically shut off if any portion of the monitoring system is disabled or disconnected? Yes No* N/A For electronic LLDs, does the turbine automatically shut off if any portion of the monitoring system malfunctions or fails a test? Yes No* N/A For electronic LLDs, have all accessible wiring connections been visually inspected? Yes No* Were all items on the equipment manufacturer’s maintenance checklist completed? * In the Section H, below, describe how and when these deficiencies were or will be corrected. H. Comments: ___________________________________________________________________________________________ __________________________________________________________________________________________________________ __________________________________________________________________________________________________________ __________________________________________________________________________________________________________ __________________________________________________________________________________________________________ __________________________________________________________________________________________________________ __________________________________________________________________________________________________________ __________________________________________________________________________________________________________ __________________________________________________________________________________________________________ __________________________________________________________________________________________________________ __________________________________________________________________________________________________________ Monitoring System Certification Page 3 of 4 12/07 ✔ ✔ ✔ ✔ ✔ ✔ ✔ ✔ ✔ ✔ ✔ ✔ ✔ ✔ ✔ ✔ !" !" !" ! ## $%& ! ’ %( )&*(## +&#,-.)/# 0&%#1#*2 3&$451#*2 6&7(8 9&%55 #80#,5 :&;5< ’ %( )&*(## +&#,-.)/# 0&%#1#*2 3&$451#*2 6&7(8 9&%55 #80#,5 :&;5< ’ %( )&*(## +&#,-.)/# 0&%#1#*2 3&$451#*2 6&7(8 9&%55 #80#,5 :&;5< ’ %( )&*(## +&#,-.)/# 0&%#1#*2 3&$451#*2 6&7(8 9&%55 #80#,5 :&;5< (818)452-9931 IDECOInc. TONYAPICENO 5634STINERD CA 93313 12/10/15 CK2701270 BAKERSFIELD,CA vmiildt FEPETRO N/A N/A VAPORLESS LD-2000 FIBERGLASS 2" 12/10/15 87 91 150'150' 26PSI 26PSI 3.0GPH 3.0GPH Page ____ of ____ SWRCB, January 2006 Spill Bucket Testing Report Form This form is intended for use by contractors performing annual testing of UST spill containment structures. The completed form and printouts from tests (if applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. 1.FACILITY INFORMATION Facility Name: Date of Testing: Facility Address: Facility Contact: Phone: Date Local Agency Was Notified of Testing: Name of Local Agency Inspector (if present during testing): 2.TESTING CONTRACTOR INFORMATION Company Name: IDECO INC. Technician Conducting Test: Credentials1: CSLB Contractor ICC Service Tech. SWRCB Tank Tester Other (Specify) __________________License Number(s): 744619 License Type: C10 / A / HAZ 3.SPILL BUCKET TESTING INFORMATION Test Method Used: Hydrostatic Vacuum Other: Visual Lake Test (Specify)_____________________Test Equipment Used: Measuring Device Equipment Resolution: N/A Identify Spill Bucket (By Tank Number, Stored Product, etc.) Bucket Installation Type: Direct Bury Contained in Sump Direct Bury Contained in Sump Direct Bury Contained in Sump Direct Bury Contained in Sump Bucket Diameter: Bucket Depth: Wait time between applying vacuum/water and start of test: N/A N/A N/A N/A Test Start Time (TI): Initial Reading (RI): Test End Time (TF): Final Reading (RF): Test Duration (TF – TI): 1 hr. 1 hr. 1 hr. 1 hr. Change in Reading (RF -RI): Pass/Fail Threshold or Criteria: 0.002 in. 0.002 in. 0.002 in. 0.002 in. Test Result: Pass Fail Pass Fail Pass Fail Pass Fail Comments – (include information on repairs made prior to testing, and recommended follow-up for failed tests) Spill Box manufacture: CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING I hereby certify that all the information contained in this report is true, accurate, and in full compliance with legal requirements. Technician’s Signature:Date: 1 State laws and regulations do not currently require testing to be performed by a qualified contractor. However, local requirements may be more stringent. CK2701270 5634STINERD TONYAPICENO RICKGRIFFITH Rick Griffith Digitally signed by Rick Griffith DN: cn=Rick Griffith, o=IDECO Inc., ou, email=griffithdaddy@gmail.com, c=US Date: 2015.12.10 13:22:00 -08'00' ✔ UNL-REGFILL ✔ 11" 11" 9:00AM 10.5" 10:00AM 10.5" 1HR 0.0 ✔ UNL-REGVR ✔ 11" 11" 12:30PM 10.5" 1:30PM 10.5" 1HR 0.0 ✔ BAKERSFIELD,CA 661-834-8625 UNL-PREMFILL ✔ 11" 11" 9:00AM 10.5" 10:00AM 10.5" 1HR 0.0 ✔ ✔ 12/10/15 12/10/15 93313 UNL-PREMVR ✔ 11" 11" 12:30PM 10.5" 1:30PM 10.5" 1HR 0.00 ✔ 2701270 12-10-15 < I10100 DEC 10, 2015 1:40 PM CIRCLE K 2701270 5634 STINE RD. BAKERSFIELD, CA 80749873405001 SYSTEM STATUS REPORT ISD GROSS PRES WARN > < I20100 DEC 10, 2015 1:40 PM CIRCLE K 2701270 5634 STINE RD. BAKERSFIELD, CA 80749873405001 IN-TANK INVENTORY TANK PRODUCT VOLUME TC VOLUME ULLAGE HEIGHT WATER TEMP 1 UNL-REG(005) 9125 9106 5851 68.87 0.00 62.85 2 UNL-PREM 7029 6996 4820 66.63 0.00 66.54 > < I51700 DEC 10, 2015 1:40 PM SYSTEM TYPE AND LANGUAGE FLAG SYSTEM UNITS U.S. SYSTEM LANGUAGE ENGLISH SYSTEM DATE/TIME FORMAT MON DD YYYY HH:MM:SS xM > < I50F00 DEC 10, 2015 1:40 PM MON DD YYYY HH:MM:SS xM > < I60100 DEC 10, 2015 1:40 PM Page 1 2701270 12-10-15 TANK CONFIGURATION DEVICE LABEL CONFIGURED 1 UNL-REG(005) ON 2 UNL-PREM ON 3 OFF 4 OFF > < I60200 DEC 10, 2015 1:40 PM TANK PRODUCT LABEL TANK PRODUCT LABEL 1 UNL-REG(005) 2 UNL-PREM 3 4 > < I60300 DEC 10, 2015 1:40 PM TANK PRODUCT CODE TANK PRODUCT LABEL 1 UNL-REG(005) A 2 UNL-PREM B 3 3 4 4 > < I60400 DEC 10, 2015 1:40 PM TANK FULL VOLUME TANK PRODUCT LABEL GALLONS 1 UNL-REG(005) 14976 2 UNL-PREM 11849 3 0 4 0 > < I60700 DEC 10, 2015 1:41 PM TANK DIAMETER TANK PRODUCT LABEL INCHES 1 UNL-REG(005) 120.00 2 UNL-PREM 117.75 3 0.00 Page 2 2701270 12-10-15 4 0.00 > < I60900 DEC 10, 2015 1:41 PM TANK THERMAL COEFFICIENT TANK PRODUCT LABEL 1 UNL-REG(005) 0.000700 2 UNL-PREM 0.000700 3 0.000000 4 0.000000 > < I61200 DEC 10, 2015 1:41 PM TANK MANIFOLDED PARTNERS TANK PRODUCT LABEL SIPHON MANIFOLDED TANKS LINE MANIFOLDED TANKS 1 UNL-REG(005) NONE NONE 2 UNL-PREM NONE NONE 3 NONE NONE 4 NONE NONE > < I62100 DEC 10, 2015 1:41 PM TANK LOW PRODUCT LIMIT TANK PRODUCT LABEL GALLONS 1 UNL-REG(005) 1084 2 UNL-PREM 900 3 0 4 0 > < I62200 DEC 10, 2015 1:41 PM TANK HIGH PRODUCT LIMIT TANK PRODUCT LABEL GALLONS 1 UNL-REG(005) 14227 2 UNL-PREM 11256 3 0 4 0 > < I62300 DEC 10, 2015 1:41 PM TANK OVERFILL LEVEL LIMIT Page 3 2701270 12-10-15 TANK PRODUCT LABEL GALLONS 1 UNL-REG(005) 13478 2 UNL-PREM 10664 3 0 4 0 > < I62400 DEC 10, 2015 1:41 PM TANK HIGH WATER LEVEL LIMIT TANK PRODUCT LABEL INCHES 1 UNL-REG(005) 2.5 2 UNL-PREM 2.5 > < I62800 DEC 10, 2015 1:41 PM TANK MAXIMUM VOLUME LIMIT TANK PRODUCT LABEL GALLONS 1 UNL-REG(005) 14976 2 UNL-PREM 11849 3 0 4 0 > < I62900 DEC 10, 2015 1:41 PM TANK DELIVERY REQUIRED LIMIT TANK PRODUCT LABEL GALLONS 1 UNL-REG(005) 748 2 UNL-PREM 947 3 0 4 0 > < I70300 DEC 10, 2015 1:41 PM LIQUID TYPE SENSOR LOCATION TYPE 1 87 ANNULAR TRI-STATE (SINGLE FLOAT) 2 87 TURBINE TRI-STATE (SINGLE FLOAT) 3 91 ANNULAR TRI-STATE (SINGLE FLOAT) 4 91 TURBINE TRI-STATE (SINGLE FLOAT) 5 TRI-STATE (SINGLE FLOAT) 6 TRI-STATE (SINGLE FLOAT) 7 TRI-STATE (SINGLE FLOAT) Page 4 2701270 12-10-15 8 TRI-STATE (SINGLE FLOAT) > < I20600 DEC 10, 2015 1:41 PM CIRCLE K 2701270 5634 STINE RD. BAKERSFIELD, CA 80749873405001 TANK ALARM HISTORY TANK 1 UNL-REG(005) LOW PRODUCT ALARM NOV 4, 2015 2:18 PM HIGH PRODUCT ALARM APR 23, 2015 9:46 AM PROBE OUT APR 23, 2015 9:47 AM APR 23, 2015 9:45 AM LOW TEMP WARNING APR 23, 2015 9:48 AM TANK 2 UNL-PREM HIGH PRODUCT ALARM APR 23, 2015 9:31 AM PROBE OUT APR 23, 2015 9:35 AM APR 23, 2015 9:29 AM MAX PRODUCT ALARM APR 23, 2015 9:31 AM LOW TEMP WARNING APR 23, 2015 9:36 AM APR 23, 2015 9:31 AM > < I30200 DEC 10, 2015 1:42 PM CIRCLE K 2701270 5634 STINE RD. BAKERSFIELD, CA 80749873405001 LIQUID ALARM HISTORY REPORT SENSOR LOCATION 1 87 ANNULAR DEC 10, 2015 11:39 AM FUEL ALARM DEC 10, 2015 11:39 AM FUEL ALARM Page 5 2701270 12-10-15 DEC 10, 2015 11:39 AM FUEL ALARM 2 87 TURBINE DEC 10, 2015 10:46 AM SENSOR OUT ALARM DEC 10, 2015 9:09 AM FUEL ALARM APR 23, 2015 9:18 AM FUEL ALARM 3 91 ANNULAR DEC 10, 2015 11:36 AM FUEL ALARM DEC 10, 2015 10:46 AM SENSOR OUT ALARM DEC 10, 2015 9:11 AM FUEL ALARM 4 91 TURBINE DEC 10, 2015 10:46 AM SENSOR OUT ALARM DEC 10, 2015 10:07 AM FUEL ALARM DEC 10, 2015 9:12 AM FUEL ALARM > < I31600 DEC 10, 2015 1:42 PM CIRCLE K 2701270 5634 STINE RD. BAKERSFIELD, CA 80749873405001 SMART SENSOR ALARM HISTORY REPORT SENSOR LOCATION 1 DISP 1-2 AFM 2 DISP 3-4 AFM 3 DISP 5-6 AFM 4 DISP 7-8 AFM 5 DISP 1-2 VPS > < I34200 DEC 10, 2015 1:42 PM > < I34700 DEC 10, 2015 1:42 PM > < I38200 DEC 10, 2015 1:42 PM > < I10100 DEC 10, 2015 1:42 PM CIRCLE K 2701270 5634 STINE RD. Page 6 2701270 12-10-15 BAKERSFIELD, CA 80749873405001 SYSTEM STATUS REPORT ISD GROSS PRES WARN > < I90200 DEC 10, 2015 1:42 PM SOFTWARE REVISION LEVEL VERSION 328.03 SOFTWARE# 346328-100-D CREATED - 08.06.06.17.21 S-MODULE# 330160-004-a SYSTEM FEATURES: PERIODIC IN-TANK TESTS ANNUAL IN-TANK TESTS ISD > Page 7