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Appendix VI
Copies of Monitoring System Certification form and UST Monitoring Plot Plan
MONITORING SYSTEM CERTIFICA'
For Use ByAllJurisdictions Within the State ofCalifomi
Authority Cited: Chapter 6.7, Health and Safety Code; Chapter 16, Divislot
Regulations
This form must be used to document testing and servicing of monitoring equipment A separate
each monitoring system control panel by the technician who performs the work. A copy of this
owner /operator. The owner /operator must submit a copy ofthis forth to the local agency regulating
General Information
Facility Name: lY
Site Address /k City: J'S0Q•(20PS2`
Facility Contact Person: (/ "l %C l--. Contact Phone No.:
Make/Model of Monitoring System: 7z X -tW Date of TE
B. Inventory of Equipment Tested/Certified
Check the annronriata hn :ea to Indinata rxnerific antdnmant inanar_todraarvirad-
at hftp: / /www.swrcb.ca.gov.)
Gu
3, TWO 23, Califomia Code of
mrtification or report must be prepared for
form must be provided to the tank system
UST systems within 30 days oftest date.
Bldg. No.:
D rip: Ramey
Tank ID: Tank ID:
in -Tank Gauging Probe. Model: b In -Tank Gauging Probe. Model:
Of Annular Space orVault Sensor. Model: – Annular Space orVault Se mor. Model:
tf Piping Sump / Trench Sensor(s). Model: Piping Sump / Trench or(s). Model:
FlII Sump Sensor(s). Model: Fill Sump Sensor(s). Model:
Mechanical Line Leak Detector. Model: Mechanical Una Leak Detector. Model:
Electronic Line Leak Detector. Model: Electronic Line Leak Dete or. Model:
Tank Overfill / High -Level Sensor. Model: Tank Overfill / High -Level Eensor. Model:
Other (specify equipment and model in Section E on Page 2). Other (se2cify 2quipment and model in Section E on P892 2).
TanklD: TanklD
In -Tank Gauging Probe. Model: In -Tank Gauging Probe. Model:
Annular Space or Vault Sensor. Model: Annular Space orVault Se isor. Model:
Piping Sump / Trench Sensor(s). Model: Piping Sump / Trench Sort or(s). Model:
Fill Sump Sensor(s). Model: Fill Sump Sensor(s). Model:
Mechanical Line Leak Detector. Model: Mechanical Line Leak Deft ctor. Model:
Electronic Line Leak Detector. Model: Electronic Line Leak Detec or. Model:
Tank Overfill / High -Level Sensor. Model: Tank Overfill / High -Level nsor. Model:
Others u meM type and model In Section E on Pa e 2). Other equipment t pe and model in Section Eon Pa 2 .
Dispenser ID: Dispenser ID:
DispenserContainment Sensor(s). Model: DispenserContainment Se sor(s). Model:
Shear Valve(s). Shear Valve(s).
Dispenser Containment Floats and Chain(s). Dispenser Containment Flo s and Chaln s .
Disperser ID: Dispenser ID:
O Dispenser Containment Sensor(s). Model: Dispenser Containment Se sor(s). Model:
Shear Vahre(s). Shear Valve(s).
Disp2nser Containment Floats and Chains . Dis nser Containment FIc at(s and Chains .
Dispenser ID: Dispenser ID:
Dispenser Containment Sensor(s). Model: Dispenser Containment Se sor(s). Model:
Shear Valve(s). Shear Valve(s).
Dise=r Containment Floats and Chains Dispenser Containment Flo s and Chain(s).
it the tacility contains more tanks or Dispensers, copy trds torn. Include Rmtormation Tor every tanK and
C. Certification - I certify that the equipment Identified in this document was Inspected
guldelines. Attached to this Certification Is information (e.g. manufacturers' ctmecklIs
and a Plot Plan showing the layout of monitoring equipment. For any nt ca
copy of the report; (check all thatapply): System set-up arm h tory re
Technician H
Certification
Testing Com
Testing Com
Monitoring System Certification Page 1 of 4
dispenser at the reality.
servi In accordance with the manufacturers'
nscessary to verify that this Information Is correct
of gone rating such reports, I have also attached a
Date 2LVI
12!07
1 1 2/21/07
D. Results of Testing/Servicing
Software Version Installed:. 2 -'5w /0
Comalete 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 NW Were all sensors installed at lowest point of secondary containment and positioned so Md 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?
If N/A
Yes No* For pressurized piping systems, does the turbine automatically shut down if the pip ng secondary containment monitoring system
4r WA detects a leak, fails to operate, or is electrically disconnected? Ifyes: which sensors in late positive shut -down? (Check all that apply)
Sump/Trench Sensors; Dispenser Containment Sensors. Did you confirm positive shut -down due to leaks mid sensor
fai]ure/disconnection? Yes; No.
Yes No' For tank systems that utilize the monitoring system as the primary tank overfill wamir g device (i.e. no mechanical overfill prevention
4C N/A valve is installed), is the overfill warning alarm visible and audible at the tank fill points and operating properly? If so, at what percent
of tank capacity does the alarm trigger? %
Yes* No Was any monitoring equipment replaced? If yes, Identity specific sensors, prob s, or other equipment replaced and fist the
manufacturer name and model for all replacement parts in Section E, below.
Yes'! V 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 repo if applicable
Yes No* Is all monitoring equipment operational per manufacturer's specifications?
In Sea
E
Mon]
Monitoring System Certification
UST Monitoring Site Plan
Site Address:
r uie ............... D iese r .' 'nk ::
Date map was drawn:
Instructions
If you already have a diagram that shows all required information, you may include it rather ti
Certification. On your site plan, show the general layout of tanks and piping. Clearly identify low
monitoring system control panels; sensors monitoring tank annular spaces, sumps, dispenser
containment areas; mechanical or electronic line leak detectors; and in -tank liquid level probe:
provided, note the date this Site Plan was prepared.
Monitoring System Certification Page 4 of 4
n this page, with your Monitoring System
o.
5ns
of the following equipment, if installed:
n, spill containers, or other secondary
f used for leak detection). In the space
12(07
4 I 2/21/07