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Home My WebLink About1129 UNION AVENUE (4)Appendix VI Copies of Monitoring System Certification form and UST Monitoring Plot Plan available at htto: / /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 96, 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 m(" W it a copy of this form to the local agency regulating UST systems within 30 days of test date. A. General Information Facility Name: q ( V t Bldg. No.: Site Address: 1 I q 1 iq, 0 4 City: `l S Zip: Facility Contact Person: IN& Contact Phone No.: ( Make/Model of Monitoring System: ail% Date of Testing /Servicing: // ZU 1-0 B. Inventory of Equipment Tested /Certified Check the appropriate boxes to indicatespecific equipment inspected/serviced: Tank ID: I Tank ID: In -Tank Gauging Probe. Model: In -Tank Gauging Probe. Model: Annular Space or Vault Sensor. Model: Annular Space or Vault Sensor. Model: -7 O' U Piping Sump / Trench Sensor(s). Model: c - Piping Sump / Trench Sensor(s). Model: 0' Z Fill Sump Sensor(s). Model: _ z - ;' K Fill Sump Sensor(s). Model: — Z Mechanical Line Leak Detector. Model: 0 Mechanical Line Leak Detector. Model: Electronic Line Leak Detector. Model: L 4_- b B-`Electronic Line Leak Detector. Model: Tank Overfill / High -Level Sensor. Model: Tank Overfill / High -Level Sensor. Model: Other (specify equipment t e and model in Section E on Page 2). Other (specify equipment t e and model in Section E on Pa2e 2). Tank ID: —5 Tank ID: In -Tank Gauging Probe. Model: 0 In -Tank Gauging Probe. Model: 0 Annular Space or Vault Sensor. Model: tom- Annular Space or Vault Sensor. Model: f C Piping Sump / Trench Sensor(s). Model: 7 t, Piping Sump / Trench Sensor(s). Model: O FX- Fill Sump Sensor(s). Model: :zk UZQ(,1- 17-4 f Fill Sump Sensor(s). Model: 0 Mechanical Line Leak Detector. Electronic Line Leak Detector. Model: Model: Mechanical Line Leak Detector. Flectronic Line Leak Detector. Model: Model: Tank Overfill / High -Level Sensor. Model: Tank Overfill / High -Level Sensor. Model: Others if a ui ment tXge and model in Section E on Page 2). Others cif e ui ment a and model in Section E on Pa e 2 . Dispenser ID: t / Dispenser ID: fQ Dispenser Containment Se sor(s). Model: ig3F 37-3 V Dispenser Containmen Sensor(s). Model: ? z 3 Yd Shear Valve(s). 4 —Shear Valve(s). Dispenser Containment Floats and Chains . Dis enser Containment Floats and Chain(s). Dispenser ID: 91A Dispenser ID: L Dispenser Containm nt Sensor(s). Model: — tZ Dispenser Containmen Sensor(s). Model: 0 -3 "2_ Ur_ Shear Valve(s). a—Shear Valve(s). 0 Dispenser Containment Floats and Chain(s). 0 Dispenser Containment Floats and Chains . Dispenser ID: Dispenser ID: 0 Dispenser Containment Sensor(s). Model: Dispenser Containment Sensor(s). Model: Shear Valve(s). Shear Valve(s). 0 Dispenser Containment Floats and Chains 0 Dispenser Containment Floats and Chains . 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 appply`): System set -up Alarm h eport Technician Name (print): 74, 1 t'SS1 11 rI11%d'i1,—S Signature: Certification No.: v J License. No.: ( 0S-75 Testing Company Name: _ 1 1 Phone No.:( 66( Testing Company Address: . L) Cp 67 o Date of Testing /Servicing: It ZV y Monitoring System Certification Page 1 of 4 12107 2/21/07 D. Results of Testing/Servicing % Software Version Installed: y v Complete the followina 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' If alarms are relayed to a remote monitoring station, is all communications equipment (e.g. modem) operational? N/A Yes No' For pressurized piping systems, does the turbine automatically shut down if the piping secondary containment monitoring system N/A detects a leak, fails to operate, or is electrically disconnected? If yes: which sensors initiate positive shut -down? (Check all that apply) ye" Sump/Trench Sensors; Dispenser Containment Sensors. Did you confirm positive shut -down due to leaks and sensor failure /disconnection ?sFWes; No. Yes No' For tank systems that utilize the monitoring system as the primary tank overfill warning device (i.e. no mechanical overfill prevention N/A 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' jfiy 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 es, 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 12107 2/21/07 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 0 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? 0 Yes No* Was accuracy of system water level readings tested? Yes 0 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: K,Yes No* For equipment start-up or annual equipment certification, was a leak simulated to verify LLD performance? (Check all N/A that apply) Simulated leak rate: 'X-3 g.p.h.; 0.1 g.p.h ; 0.2 g.p.h. of , Yes No* Were all LLDs confirmed operational and accurate within regulatory requirements? Yes No* Was the testing apparatus properly calibrated? Yes No* For mechanical LLDs, does the LLD restrict product flow if it detects a leak? N/A Yes No* For electronic LLDs, does the turbine automatically shut off if the LLD detects a leak? N/A Yes No* For electronic LLDs, does the turbine automatically shut off if any portion of the monitoring system is disabled or 0 N/A disconnected? Yes No* For electronic LLDs, does the turbine automatically shut off if any portion of the monitoring system malfunctions or N/A fails a test? lZe Yes No* For electronic LLDs, have all accessible wiring connections been visually inspected? N/A 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 12107 3 2/21/07 Monitoring System Certification UST Monitoring Site Plan Site Address: 7:;," Date map was drawn: 11 / 16 / ?IQ( U Instructions If you already have a diagram that shows all required information, you may include it, rather than this page, with your Monitoring System Certification. On your site plan, show the general layout of tanks and piping. Clearly identify locations of the following equipment, if installed: monitoring system control panels; sensors monitoring tank annular spaces, sumps, dispenser pans, spill containers, or other secondary containment areas; mechanical or electronic line leak detectors; and in -tank liquid level probes (if used for leak detection). In the space provided, note the date this Site Plan was prepared. Monitoring System Certification Page 4 of 4 12/07 4 2/21/07