HomeMy WebLinkAboutGAS FMC 2020CERS = California Environmental Reporting System, ID = Identification, ICC = International Code Council, Y = Yes, N = No, NA = Not Applicable
UNDERGROUND STORAGE TANK
MONITORING SYSTEM CERTIFICATION FORM (Page 1 of 6)
This form must be used to document testing and servicing of underground storage tank (UST) monitoring equipment. A copy
of this form must be provided to the UST owner or operator. The owner or operator must submit a copy of this form to the local
agency regulating the USTs within 30 days of the date of the monitoring system certification.
I. FACILITY INFORMATION
CERS ID Date of Monitoring System Certification
Business Name (Same as Facility Name or DBA-Doing Business As)
Business Site Address City ZIP Code
II. UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION
Name of Company Performing the Certification Phone #
Mailing Address
Name of UST Service Technician Performing the Certification (Print as shown on the ICC Certification)
Contractor / Tank Tester License # ICC Certification # ICC Certification Expiration Date
Monitoring System Training and Certifications (List all applicable certifications.) Expiration Date
III. RESULTS OF TESTING / SERVICING
Indicate and attach the following reports if the monitoring equipment is capable of generating either. Y N NA Monitoring System Set-up Alarm History Report
Was any monitoring equipment replaced?
(If “Yes,” identify the specific devices replaced and list the manufacturer and model for all replacement parts in section IV below.)
Was damage, debris, or liquid found inside any secondary containment systems?
(If “Yes,” describe what was found in section IV below.)
Is all monitoring equipment operational per manufacturer’s specifications?
(If “No,” describe why in section IV below.)
IV. COMMENTS
If directed to use this section, describe how and when the issues were or will be corrected.
V. CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS TESTING
I hereby certify that the equipment identified in this document was inspected/serviced in accordance with California Code of
Regulations, Title 23, Division 3, Chapter 16, Section 2638 and all information contained herein is true and accurate. Attached to
this certification is information (e.g., manufacturers' checklists, monitoring system set-up, alarm history report, etc.) necessary
to verify that this information and the site plan showing the layout of UST system is complete and accurate.
UST Service Technician Signature
Building #
ID = Identification, SW = Single-Walled, VPH = Vacuum/Pressure/Hydrostatic, LLD = Line Leak Detector
UNDERGROUND STORAGE TANK
MONITORING SYSTEM CERTIFICATION FORM (Page 2 of 6)
VI. INVENTORY OF EQUIPMENT CERTIFIED
A separate Monitoring System Certification Form must be prepared for each monitoring system control panel.
Make of Monitoring System Control Panel Model of Monitoring System Control Panel Software Version Installed
Check the appropriate boxes to indicate specific equipment inspected/serviced.
Monitoring Device Used Device Model # Monitoring Device Used Device Model #
TANK ID:
(By tank number, stored product, etc.)
TANK ID:
(By tank number, stored product, etc.)
In-Tank Gauging (SW Tank) In-Tank Gauging (SW Tank)
Annular Space or Vault Sensor Annular Space or Vault Sensor
VPH Sensor VPH Sensor
Product Piping Product Piping
Mechanical LLD Mechanical LLD
Electronic LLD Electronic LLD
VPH Sensor (Piping) VPH Sensor (Piping)
Sump Sensor Sump Sensor
VPH Sensor (Sump) VPH Sensor (Sump)
Fill Piping Fill Piping
VPH Sensor (Piping) VPH Sensor (Piping)
Sump Sensor Sump Sensor
VPH Sensor (Sump) VPH Sensor (Sump)
Vent Piping Vent Piping
VPH Sensor (Piping) VPH Sensor (Piping)
Sump Sensor Sump Sensor
VPH Sensor (Sump) VPH Sensor (Sump)
Vapor Recovery Piping Vapor Recovery Piping
VPH Sensor (Piping) VPH Sensor (Piping)
Sump Sensor Sump Sensor
VPH Sensor (Sump) VPH Sensor (Sump)
Monitoring Device Used
Device Model # Monitoring Device Used
Device Model #
TANK ID:
(By tank number, stored product, etc.)
TANK ID:
(By tank number, stored product, etc.)
In-Tank Gauging (SW Tank) In-Tank Gauging (SW Tank)
Annular Space or Vault Sensor Annular Space or Vault Sensor
VPH Sensor VPH Sensor
Product Piping Product Piping
Mechanical LLD Mechanical LLD
Electronic LLD Electronic LLD
VPH Sensor (Piping) VPH Sensor (Piping)
Sump Sensor Sump Sensor
VPH Sensor (Sump) VPH Sensor (Sump)
Fill Piping Fill Piping
VPH Sensor (Piping) VPH Sensor (Piping)
Sump Sensor Sump Sensor
VPH Sensor (Sump) VPH Sensor (Sump)
Vent Piping Vent Piping
VPH Sensor (Piping) VPH Sensor (Piping)
Sump Sensor Sump Sensor
VPH Sensor (Sump) VPH Sensor (Sump)
Vapor Recovery Piping Vapor Recovery Piping
VPH Sensor (Piping) VPH Sensor (Piping)
Sump Sensor Sump Sensor
VPH Sensor (Sump) VPH Sensor (Sump)
ID = Identification, VPH = Vacuum/Pressure/Hydrostatic, UDC = Under-Dispenser Containment
UNDERGROUND STORAGE TANK
MONITORING SYSTEM CERTIFICATION FORM (Page 3 of 6)
Monitoring Device Used Device Model # Monitoring Device Used Device Model #
VENT / TRANSITION SUMP ID: VENT / TRANSITION SUMP ID:
Sump Sensor Sump Sensor
VPH Sensor VPH Sensor
UDC ID: UDC ID:
Electronic Sensor Electronic Sensor
Mechanical Device Mechanical Device
VPH Sensor VPH Sensor
UDC ID: UDC ID:
Electronic Sensor Electronic Sensor
Mechanical Device Mechanical Device
VPH Sensor VPH Sensor
UDC ID: UDC ID:
Electronic Sensor Electronic Sensor
Mechanical Device Mechanical Device
VPH Sensor VPH Sensor
UDC ID: UDC ID:
Electronic Sensor Electronic Sensor
Mechanical Device Mechanical Device
VPH Sensor VPH Sensor
Other Monitored Component ID: Other Monitored Component ID:
Other (Specify in section VII.) Other (Specify in section VII.)
Other Monitored Component ID: Other Monitored Component ID:
Other (Specify in section VII.) Other (Specify in section VII.)
Other Monitored Component ID: Other Monitored Component ID:
Other (Specify in section VII.) Other (Specify in section VII.)
Include information for every underground storage tank component monitored by this monitoring system control panel. If the monitoring system
control panel monitors more components than this form accommodates, additional copies of these pages may be attached.
VII. COMMENTS
Use this section to provide additional comments about the inventory of the equipment certified.
Y = Yes, N = No, NA = Not Applicable
UNDERGROUND STORAGE TANK
MONITORING SYSTEM CERTIFICATION FORM (Page 4 of 6)
VIII. MONITORING SYSTEM AND PROGRAMMING
This section must be completed if a monitoring panel is used to perform leak detection monitoring. Y N NA
Are the visual and audible alarms operational?
Were all sensors visually inspected for kinks and breaks in the cables and for residual buildup to ensure that floats move freely,
functionally tested, and confirmed operational?
Were all sensors installed at lowest point of secondary containment and positioned so that other equipment will not interfere with
their proper operation?
Was monitoring system set-up reviewed to ensure proper settings?
Was the monitoring panel’s backup battery visually inspected, functionally tested, and confirmed operational?
Does the flow of fuel stop at the dispenser if a leak is detected in the under-dispenser containment?
Does the turbine automatically shut down if the piping secondary containment monitoring system fails to operate or is electrically
disconnected?
Does the turbine automatically shut down if the piping secondary containment monitoring system detects a leak?
Which sensors initiate positive shut down? (Check all that apply.) Sump Under-Dispenser Containment
If alarms are relayed to a remote monitoring station, is all communications equipment (e.g., modem) operational?
For any answer of “N” above, describe in Section IX how and when these deficiencies were or will be corrected.
IX. COMMENTS
X. IN-TANK GAUGING TESTING
Check this box if tank gauging is used only for inventory control. (Do not complete this section.)
Y N NA Check this box if NO tank gauging equipment is installed. (Do not complete this section.)
This section must be completed if in-tank gauging is used to perform leak detection monitoring.
Has all input wiring been inspected for kinks and breaks in the cables and for proper entry and termination, including testing for
ground faults?
Were all in-tank gauging probes visually inspected for damage and residue buildup to ensure that floats move freely, functionally
tested, and confirmed operational?
Was accuracy of system’s product level readings tested?
Was accuracy of system’s water level readings tested?
Were all probes reinstalled properly?
Were all items on the equipment manufacturer’s maintenance checklist completed?
For any answer of “N” above, describe in Section XI how and when these deficiencies were or will be corrected.
XI. COMMENTS
GPH = Gallons Per Hour, Y = Yes, N = No, NA = Not Applicable, VPH = Vacuum/Pressure/Hydrostatic, ID = Identification
UNDERGROUND STORAGE TANK
MONITORING SYSTEM CERTIFICATION FORM (Page 5 of 6)
XII. LINE LEAK DETECTOR TESTING
Check this box if line leak detectors (LLD) are NOT installed. (Do not complete this section.) Y N NA This section must be completed if LLDs are installed.
Was a leak simulated to verify LLD performance?
(Check all that apply.) Simulated leak rate verified: 3 GPH 0.1 GPH 0.2 GPH
Was the testing apparatus properly calibrated?
For emergency generator tank systems, does the LLD create an audible and visual alarm when a leak is detected?
For mechanical LLDs, does the LLD restrict the flow through the pipe when a leak is detected?
For electronic LLDs, does the turbine automatically shut off when a leak is detected?
For electronic LLDs, does the turbine automatically shut off if any portion of the monitoring system is disabled or disconnected?
For electronic LLDs, does the turbine automatically shut off if any portion of the monitoring system malfunctions or fails a test?
For electronic LLDs, have all accessible wiring connections been visually inspected for kinks and breaks?
Were all items on the equipment manufacturer’s maintenance checklist completed?
Were all LLDs confirmed operational within regulatory requirements?
For any answer of “N” above, describe in Section XIII how and when these issues were or will be corrected.
XIII. COMMENTS
XIV. VACUUM / PRESSURE / HYDROSTATIC MONITORING EQUIPMENT TESTING
Check this box if VPH monitoring is NOT used. (Do not complete this section.)
This section must be completed if VPH monitoring is used to perform leak detection monitoring.
System Type (Mark all that apply.) Vacuum Pressure Hydrostatic
Sensor ID Component(S) Monitored By This Sensor Sensor Functionality
Test
Interstitial Communication
Test
Pass Fail Pass Fail
Pass Fail Pass Fail
Pass Fail Pass Fail
Pass Fail Pass Fail
Pass Fail Pass Fail
Pass Fail Pass Fail
Pass Fail Pass Fail
Pass Fail Pass Fail
Pass Fail Pass Fail
Pass Fail Pass Fail
Pass Fail Pass Fail
Pass Fail Pass Fail
How was interstitial communication verified? Simulated Leak at Far Ends of the Interstitial Space Visual Inspection
Other (Describe the method in section XV below.) Gauge
Was the vacuum or pressure restored to operating levels in all interstitial spaces? Yes No (Describe the reason in section XV below.)
For any answer of “Fail” above, describe in Section XV how and when these issues were or will be corrected.
XV. COMMENTS
UNDERGROUND STORAGE TANK
MONITORING SYSTEM CERTIFICATION FORM (Page 6 of 6)
XVI. MONITORING SITE PLAN
Date site map was prepared:
If you already have a site plan that shows all required information, you may include it, rather than this page, with your Monitoring System
Certification Form. The site plan must show the general layout of tanks and piping and clearly identify locations of the following equipment,
if installed: 1) monitoring system control panels; 2) in-tank liquid level probes (if used for leak detection); 3) devices monitoring tank
annular spaces or vault; 4) devices monitoring product piping; 5) devices monitoring fill piping; 6) devices monitoring vent piping; 7) devices
monitoring vapor recovery piping; 8) devices monitoring vent/transition sumps; 9) devices monitoring under-dispenser containment; 10)
line leak detectors; and 11) devices monitoring any other secondary containment areas.
LEGEND