HomeMy WebLinkAboutFMC RESULTS 1-2017MONITORING 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
System set-up Alarm history report
Signature:
License. No.:804904
Phone No.:(800)339-9930
Site Address:Date of Testing/Servicing:
Page 1 of 3
20
20
MesaMarinChevron
11101Highway178 Bakersfield 93306
MohammudMuthana (661)366-4886
Veeder-RootTLS-350
10,000gal.Regular
847390-107
PLLD
847390-107
10,000gal.Plus
847390-107
PLLD
847390-107
10,000gal.Super
847390-107
847390-107
10,000gal.Diesel
847390-107
PLLD PLLD
847390-107
1-2 3-4
attached a copy of the report; (check all that apply):
Technician Name (print): Jose Ochoa
Certification No.: B35931
Testing Company Name: Confidence UST Services,
Inc.11101Highway178 Bakersfield,CA93306
Monitoring System Certification
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:
Page 3 of 3
89 plld was replaced. Confirm compliance by retesting
Leak Detector Test Results Sheet
Customer Address: Work Order: Site Address:
Test Date:
Site Contact: Phone:
Technician: Phone: 800-339-9930 ICC No.:
Product Type LLD Type Model Serial No. Check
Valve
Holding
Pressure
Bleed
Off ML.
Leak
Rate
Tested:
Pass/Fail
3 gph @
10 psi
3 gph @
10 psi
3 gph @
10 psi
3 gph @
10 psi
3 gph @
10 psi
3 gph @
10 psi
3 gph @
10 psi
3 gph @
10 psi
Technician Name:
Signature:
Technician No.:
Date:
MuthanaCorp.dbaMesaMarinChevron
11101Highway178
Bakersfield,CA93306
38219A
8004551-UT
Plus Electronic PLLD
Jose Ochoa
(661)366-4886MohammudMuthana
Bakersfield,CA93306
11101Highway178
MesaMarinChevron
19 PSI 25 ML Pass
Jose Ochoa 8004551-UT
01/20/2017
01/20/2017