HomeMy WebLinkAboutFMC 20182/21/07 1
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.
$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: ___________________
%Inventory of Equipment Tested/CertifiedCheck the appropriate boxes to indicate specific equipment inspected/serviced:
Tank ID: ____________________________________________
2/21/072
D. Results of Testing/Servicing
Software Version Installed: _____________________________________
Complete the following checklist:
2/21/073
F. In-Tank Gauging / SIR Equipment:
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:
Technician Conducting Test:
Credentials1: CSLB Contractor ICC Service Tech. SWRCB Tank Tester Other (Specify) __________________
License Number(s):
3. SPILL BUCKET TESTING INFORMATION
Test Method Used: Hydrostatic Vacuum Other
Test Equipment Used: Equipment Resolution:
Identify Spill Bucket (By Tank
Number, Stored Product, etc.)
1234
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:
Test Start Time (TI):
Initial Reading (RI):
Test End Time (TF):
Final Reading (RF):
Test Duration (TF –TI):
Change in Reading (RF -RI):
Pass/Fail Threshold or
Criteria:
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)
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.
Plaza Towers 07/17/2018
3015 Wilson Rd
Michael Ruiz
6-08-2018
Kris Karns/ Malcom Moore
Confidence UST Services, Inc.
Frank Amestoy
804904
Lake Test 0.0625"
12.00"
14.00"
30 minutes
9:00am
13.00"
10:00am
13.00"
60 minutes
0.00"
0.0625"
07/17/2018
✔✔
✔
✔
✔
Diesel
8374998