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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: ______ARCO AMPM _________________________________________________ Bldg. No.:___________________
Site Address: __2051 Taft Hwy. ___________________________ City: _Bakersfield ____________ Zip: ____________________
Facility Contact Person: ___________________________________________ Contact Phone No.: (_______)__________________________
Make/Model of Monitoring System: Veeder-Root TLS-350________________________ Date of Testing/Servicing: _1_/_30_/ 2018______ B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced:
Tank ID: _North 87 UL_______________________________
X In-Tank Gauging Probe. Model: __Mag.______________
X Annular Space or Vault Sensor. Model: _794390-409 ______
X Piping Sump / Trench Sensor(s). Model: _794380-208 ____ _
Fill Sump Sensor(s). Model: ____________________
X Mechanical Line Leak Detector. Model: __FX1V __________
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: _ DIESEL___ __________________________
X In-Tank Gauging Probe. Model: __Mag.______________
X Annular Space or Vault Sensor. Model: _794390-409 ______
X Piping Sump / Trench Sensor(s). Model: _794380-208 ____ _
Fill Sump Sensor(s). Model: ____________________
X Mechanical Line Leak Detector. Model: __FX1DV __________
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: _ 91 UL___ ____________________________
X In-Tank Gauging Probe. Model: __Mag.______________ X Annular Space or Vault Sensor. Model: _794390-409 ______
X Piping Sump / Trench Sensor(s). Model: _794380-208 ____ _
Fill Sump Sensor(s). Model: ____________________ X Mechanical Line Leak Detector. Model: __FX1V __________
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: _1-2 __________________________________
X Dispenser Containment Sensor(s). Model: _794380-208 ____ X Shear Valve(s).
Dispenser Containment Float(s) and Chain(s).
Dispenser ID: _7-8 __________________________________
X Dispenser Containment Sensor(s). Model: _794380-208 ____ X Shear Valve(s).
Dispenser Containment Float(s) and Chain(s).
Dispenser ID: _3-4 __________________________________
X Dispenser Containment Sensor(s). Model: _794380-208 ____ X Shear Valve(s).
Dispenser Containment Float(s) and Chain(s).
Dispenser ID: _9-10, 11-12 _______________________________
X Dispenser Containment Sensor(s). Model: _794380-208 ____ X Shear Valve(s).
Dispenser Containment Float(s) and Chain(s).
Dispenser ID: _5-6 __________________________________
X Dispenser Containment Sensor(s). Model: _794380-208 ____ X Shear Valve(s).
Dispenser ID: _13-14, 15-16 _______________________________
X Dispenser Containment Sensor(s). Model: _794380-208 ____ X 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): X System set-up X Alarm history report
Technician Name (print): _Bradley W. Hinsley___________________ Signature: __________________________________________________
Certification No.: _B46141 _____________________________ License. No.: _8376986______________________________
Testing Company Name: _Advanced Compliance_______________________ Phone No.:(661) 706-4321______________________
Testing Company Address: _3704 Littlefalls Ct. Bakersfield, Ca. 93312______________________ Date of Testing/Servicing: _1_/_30_/_2018________
Monitoring System Certification Page 1 of 4 12/07
2/21/07 2
D. Results of Testing/Servicing
Software Version Installed: _333.06_____________________________
Complete the following checklist:
X Yes No* Is the audible alarm operational?
X Yes No* Is the visual alarm operational?
X Yes No* Were all sensors visually inspected, functionally tested, and confirmed operational?
X 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* X N/A If alarms are relayed to a remote monitoring station, is all communications equipment (e.g. modem) operational?
X 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)
X Sump/Trench Sensors; X Dispenser Containment Sensors. Did you confirm positive shut-down due to leaks and sensor
failure/disconnection? X
Yes No*
X 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* X 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* X No
Was liquid found inside any secondary containment systems designed as dry systems? (Check all that apply)
yes, describe causes in Section E, below.
X Yes No* Was monitoring system set-up reviewed to ensure proper settings? Attach set up reports, if applicable
X 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:
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Monitoring System Certification Page 2 of 4 12/07
2/21/07 3
F. In-Tank Gauging / SIR Equipment: X 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:
X 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: X
X Yes No* Were all LLDs confirmed operational and accurate within regulatory requirements? X Yes No* Was the testing apparatus properly calibrated? X Yes No*
N/A
For mechanical LLDs, does the LLD restrict product flow if it detects a leak?
Yes No* X N/A For electronic LLDs, does the turbine automatically shut off if the LLD detects a leak?
Yes No*
X N/A
For electronic LLDs, does the turbine automatically shut off if any portion of the monitoring system is disabled or
disconnected?
Yes No*
X 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*
X N/A
For electronic LLDs, have all accessible wiring connections been visually inspected?
X 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:
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Monitoring System Certification Page 3 of 4 12/07
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: ARCO AM/PM Date of Testing: 1/30/2018
Facility Address: 2051 Taft Hwy. Bakersfield, Ca.
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: Advanced Compliance
Technician Conducting Test: Bradley W. Hinsley
Credentials1: CSLB Contractor X ICC Service Tech. SWRCB Tank Tester Other (Specify)
__________________ License Number(s): 971259
3. SPILL BUCKET TESTING INFORMATION
Test Method Used: X Hydrostatic Vacuum Other
(Specify)____________________________ Test Equipment Used: Visual Equipment Resolution:
Identify Spill Bucket (By Tank
Number, Stored Product, etc.)
1 87 UL 2 87 UL 3 91 UL 4 DIESEL
Bucket Installation Type: Direct Bury
X Contained in Sump
Direct Bury
X Contained in Sump
Direct Bury
X Contained in Sump
Direct Bury
X Contained in Sump
Bucket Diameter: 11” 11” 11” 11”
Bucket Depth: 11” 11” 11” 11”
Wait time between applying
vacuum/water and start of test: 10 min. 10 min. 10 min. 10 min.
Test Start Time (TI): 08:45 08:45 08:45 08:45
Initial Reading (RI): 9.50” 9.00” 09.00” 09.50”
Test End Time (TF): 09:45 09:45 09:45 09:45
Final Reading (RF): 9.50” 9.00” 09.00” 09.50”
Test Duration (TF – TI): 1 Hr. 1 Hr. 1 Hr. 1 Hr.
Change in Reading (RF - RI): 0.0” 0.0” 0.0” 0.0”
Pass/Fail Threshold or
Criteria: 0.25” 0.25” 0.25” 0.25”
Test Result: X Pass Fail X Pass Fail X Pass Fail X Pass Fail
Comments – (include information on repairs made prior to testing, and recommended follow-up for failed tests)
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: 1/30/2018
1 State laws and regulations do not currently require testing to be performed by a qualified contractor. However, local requirements
may be more stringent.
Advanced Compliance
3704 Littlefalls Ct.
Bakersfield, Ca. 93308
661-706-4321 Fax# 661-589-9329
VAPORLESS MANUFACTURING, INC.
LDT-890 Leak Detector Test Record
Contractor: Advanced Compliance Customer: ARCO AMPM
Date: 1/30/2018 Location: 2051 Taft Hwy. Bakersfield, Ca.
Product: 87 UL Technician: Bradley W. Hinsley
Submersible Pump Identification
Manufacturer: Redjacket Model No.:
Serial No.: Notes:
Leak Detector Identification
Manufacturer: Veeder-Root Description:
Diaphragm-type: Piston-type: FX 1V
Tamper-proof seal installed: Other Style Leak Detector:
Notes:
Leak Detector in Submersible Pump Test at Dispenser
Operating Pump Pressure (psi): 37 (para. 15)
Gallons per hour rate: 3.0 (para. 22)
Line pressure with pump shut off (psi): 13 (para. 23)
Bleed-back Test with pump off (ml): 100 (para. 26)
Step-through time to full flow (secs): 3 (para. 30)
Leak detector stays in leak search position (Yes/No): Yes (para. 42)
Leak Detector Test
Pass / Fail Notes:
Pass
*Complete thermal expansion test before failing leak detector
Advanced Compliance
3704 Littlefalls Ct.
Bakersfield, Ca. 93308
661-706-4321 Fax# 661-589-9329
VAPORLESS MANUFACTURING, INC.
LDT-890 Leak Detector Test Record
Contractor: Advanced Compliance Customer: ARCO AMPM
Date: 1/30/2018 Location: 2051 Taft Hwy. Bakersfield, Ca.
Product: 91 UL Technician: Bradley W. Hinsley
Submersible Pump Identification
Manufacturer: Redjacket Model No.:
Serial No.: Notes:
Leak Detector Identification
Manufacturer: Veeder-Root Description:
Diaphragm-type: Piston-type: FX 1V
Tamper-proof seal installed: Other Style Leak Detector:
Notes:
Leak Detector in Submersible Pump Test at Dispenser
Operating Pump Pressure (psi): 37 (para. 15)
Gallons per hour rate: 3.0 (para. 22)
Line pressure with pump shut off (psi): 15 (para. 23)
Bleed-back Test with pump off (ml): 120 (para. 26)
Step-through time to full flow (secs): 3 (para. 30)
Leak detector stays in leak search position (Yes/No): Yes (para. 42)
Leak Detector Test
Pass / Fail Notes:
Pass
*Complete thermal expansion test before failing leak detector
Advanced Compliance
3704 Littlefalls Ct.
Bakersfield, Ca. 93308
661-706-4321 Fax# 661-589-9329
VAPORLESS MANUFACTURING, INC.
LDT-890 Leak Detector Test Record
Contractor: Advanced Compliance Customer: ARCO AMPM
Date: 1/30/2018 Location: 2051 Taft Hwy. Bakersfield, Ca.
Product: DIESEL Technician: Bradley W. Hinsley
Submersible Pump Identification
Manufacturer: Redjacket Model No.:
Serial No.: Notes:
Leak Detector Identification
Manufacturer: Veeder-Root Description:
Diaphragm-type: Piston-type: FX 1DV
Tamper-proof seal installed: Other Style Leak Detector:
Notes:
Leak Detector in Submersible Pump Test at Dispenser
Operating Pump Pressure (psi): 36 (para. 15)
Gallons per hour rate: 3.0 (para. 22)
Line pressure with pump shut off (psi): 17 (para. 23)
Bleed-back Test with pump off (ml): 160 (para. 26)
Step-through time to full flow (secs): 3 (para. 30)
Leak detector stays in leak search position (Yes/No): Yes (para. 42)
Leak Detector Test
Pass / Fail Notes:
Pass
*Complete thermal expansion test before failing leak detector