HomeMy WebLinkAboutFMC 2020Appendix VI
Underground Storage Tank
Monitoring System Certification Form
CERS = California Environmental Reporting System, GPH = Gallons Per Hour, ID = Identification,
ICC = International Code Council, LLD = Line Leak Detector, NA = Not Applicable, SW = Single-
Walled, UDC = Under-Dispenser Containment, UST = Underground Storage Tank,
VPH = Vacuum/Pressure/Hydrostatic
Page 1 of 6
TYPE OF ACTION ܆ Installation ܆ Repair ܆ 12 Month
1. FACILITY INFORMATION
CERS ID
1002242
Certification Date
10-30-2020
Facility Name
Sprint - Bakersfield
Facility Address
715 E. Sumner St.
City
Bakersfield
ZIP Code
93305
2. SERVICE TECHNICIAN INFORMATION
Company Performing the Certification
Jauregui & Culver Inc.
Phone
760-743-0518
Mailing Address
959 W. Mission Ave. Escondido, CA. 92025
Service Technician Performing Test
John Culver II
Contractor/Tank Tester License Number
780231
ICC Number
8182417
ICC Expiration Date
4-16-21
3. TRAINING AND CERTIFICATIONS
Manufacturer and Test Equipment Training Certifications Expiration Date
Veeder-Root, A22531 7-13-21
4. CERTIFICATION BY SERVICE TECHNICIAN CONDUCTING TEST
I hereby certify that the monitoring system is operational in accordance with California Code
of Regulations, title 23, division 3, chapter 16, section 2638; that required supporting
documentation is attached; and all information contained herein is accurate.
Service Technician Signature Date
10-30-2020
Total # of Pages
Underground Storage Tank
Monitoring System Certification Form
Page 2 of 6
5. MONITORING SYSTEM AND PROGRAMMING
A separate Monitoring System Certification Form must be prepared for each control panel.
Make of Monitoring System
Control Panel
Veeder-Root
Model of Monitoring System
Control Panel
TLS-350
Software Version Installed
17.01
Attach the post-certification reports if the monitoring system is capable of generating
either;܈Monitoring System Set-up ܈ Alarm History Report Yes No NA
All monitoring equipment is operational per manufacturer’s specifications? ܈܆
Secondary containment systems are free of damage, debris, or liquid? ܆܈
Are the audible and visual alarms operational? ܈܆
All sensors have been: 1) visually inspected for wiring kinks, breaks and residual
buildup on floats; and 2) tested for functionality and confirmed operational? ܈܆܆
Are all sensors installed to detect a release at the earliest opportunity in the
secondary containment? ܈܆܆
The monitoring system set-up was reviewed, and proper settings confirmed? ܈܆܆
Was the monitoring control panel’s backup battery visually inspected, functionally
tested, and confirmed operational? ܈܆܆
Does the flow of fuel stop at the dispenser if a release 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 release? Which sensors initiate positive shut down?
(Check all that apply)܆ Sump ܆ UDC
܆܆܈
If monitoring system alarms are relayed to a remote monitoring center, is all
communication equipment operational? ܆܆܈
Describe all answers marked “No” or “Fail” and proposed remedy in Section 9.
List all monitoring equipment either replaced or repaired in Section 9
Underground Storage Tank
Monitoring System Certification Form
Page 3 of 6
6. SENSOR TESTING RESULTS
List only sensors tested on date of this certification. List “Sensor ID” as labeled in system
programming. Additional copies of this page may be attached to accommodate all sensors tested.
Sensor ID Sensor Model Component(s) Monitored Pass Fail
L 1 794380-208 Diesel Sump ܈ ܆
L 2 794390-409 Diesel Annular ܈ ܆
܆ ܆
܆ ܆
܆ ܆
܆ ܆
܆ ܆
܆ ܆
܆ ܆
܆ ܆
܆ ܆
܆ ܆
܆ ܆
܆ ܆
܆ ܆
܆ ܆
܆ ܆
܆ ܆
܆ ܆
܆ ܆
܆ ܆
܆ ܆
܆ ܆
܆ ܆
Describe all answers marked “No” or “Fail” and proposed remedy in Section 9.
List all monitoring equipment either replaced or repaired in Section 9
Underground Storage Tank
Monitoring System Certification Form
Page 4 of 6
7. LINE LEAK DETECTOR TESTING
܈ Check this box if line leak detectors ARE NOT installed.(Do not complete this section.)
Simulated release rate verified: (Check all that apply.)
܆ 3 GPH ܆ 0.1 GPH ܆ 0.2 GPH Yes No NA
Has the testing apparatus been 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
release is detected? ܆ ܆ ܆
For electronic LLDs, does the turbine automatically shut off when a release 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 tightness 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? ܆ ܆ ܆
LLD ID LLD Model Lines Monitored Pass Fail
܆ ܆
܆ ܆
܆ ܆
܆ ܆
܆ ܆
܆ ܆
܆ ܆
܆ ܆
܆ ܆
܆ ܆
܆ ܆
܆ ܆
Describe all answers marked “No” or “Fail” and proposed remedy in Section 9.
List all monitoring equipment either replaced or repaired in Section 9
Underground Storage Tank
Monitoring System Certification Form
Page 5 of 6
8. IN-TANK GAUGING TESTING
܈ Check this box if tank gauging is used only for inventory control.
܆ Check this box if NO tank gauging equipment is installed.
(Do not complete this section if either box is checked.)
Yes No NA
All wiring has been: 1) visually inspected for kinks, breaks and proper entry and
termination; and 2) tested 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? ܆ ܆ ܆
Probe ID Probe Model Tanks Monitored Pass Fail
܆ ܆
܆ ܆
܆ ܆
܆ ܆
܆ ܆
܆ ܆
9. COMMENTS
Describe all answers marked “No” or “Fail” and proposed remedy.
List all monitoring equipment either replaced or repaired.
Underground Storage Tank
Monitoring System Certification Form
Page 6 of 6
10. MONITORING SITE PLAN
Date site plan was prepared:
If a site plan has been prepared 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
identify locations of the monitoring panel, and all leak detection equipment and monitoring locations. Include
a legend for all symbols depicted.
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Appendix VIII
Underground Storage Tank
Spill Container Testing Report Form
CERS = California Environmental Reporting System, ID = Identification, ICC = International Code
Council
Page 1 of 2
TYPE OF ACTION ܆܆ Installation ܆ Repair ܈ 12 Month
1. FACILITY INFORMATION
CERS ID
1002242
Test Date
10-30-2020
Facility Name
Sprint - Bakersfield
Facility Address
715 E. Sumner St.
City
Bakersfield
ZIP Code
93305
2. SERVICE TECHNICIAN INFORMATION
Company Performing the Test
Jauregui & Culver Inc.
Phone
760-743-0518
Mailing Address
959 W. Mission Ave. Escondido, CA. 92025
Service Technician Performing Test
John Culver II
Contractor/Tank Tester License Number
780231
ICC Number
8182417
ICC Expiration Date
4-16-21
3. TRAINING AND CERTIFICATIONS
Manufacturer and Test Equipment Training Certifications Expiration Date
OPW, 904256 1-19-22
4. TEST PROCEDURE INFORMATION
Test Procedures Used Components Tested
5. CERTIFICATION BY SERVICE TECHNICIAN CONDUCTING TEST
I hereby certify that each spill container was tested in accordance with California Code of
Regulations, title 23, division 3, chapter 16, section 2637.1; that required supporting
documentation is attached; and all information contained herein is accurate. I understand
that test procedures shall be made available upon request by the governing authority.
Service Technician Signature Date
10-30-2020
Total # of Pages
Underground Storage Tank
Spill Container Testing Report Form
Additional copies of this page may be attached.
Page 2 of 2
6. SPILL CONTAINER DETAILS
Test Method Developed by ܆܆ Manufacturer ܈܈ Industry Standard ܆܆ Professional Engineer
Test Type ܆܆ Pressure ܆܆ Vacuum ܈܈ Hydrostatic
Tank ID Diesel
Spill Container Manufacturer:OPW
Method of Cathodic Protection ܈܈ Nonmetallic
܆܆ Other
܆܆ Nonmetallic
܆܆ Other
܆܆ Nonmetallic
܆܆ Other
܆܆ Nonmetallic
܆܆ Other
Is the spill container minimum
capacity five gallons excluding
riser volume?
܈܈ Yes
܆܆ No*
܆܆ Yes
܆܆ No*
܆܆ Yes
܆܆ No*
܆܆ Yes
܆܆ No*
Method to keep spill container
empty
܈܈ Drain
܆܆ Pump
܆܆ Other
܆܆ Drain
܆܆ Pump
܆܆ Other
܆܆ Drain
܆܆ Pump
܆܆ Other
܆܆ Drain
܆܆ Pump
܆܆ Other
Spill Container Test Results ܈܈ Pass
܆܆ Fail
܆܆ Pass
܆܆ Fail
܆܆ Pass
܆܆ Fail
܆܆ Pass
܆܆ Fail
Tank ID
Spill Container Manufacturer:
Method of Cathodic Protection ܆܆ Nonmetallic
܆܆ Other
܆܆ Nonmetallic
܆܆ Other
܆܆ Nonmetallic
܆܆ Other
܆܆ Nonmetallic
܆܆ Other
Is the spill container minimum
capacity five gallons excluding
riser volume?
܆܆ Yes
܆܆ No*
܆܆ Yes
܆܆ No*
܆܆ Yes
܆܆ No*
܆܆ Yes
܆܆ No*
Method to keep spill container
empty
܆܆ Drain
܆܆ Pump
܆܆ Other
܆܆ Drain
܆܆ Pump
܆܆ Other
܆܆ Drain
܆܆ Pump
܆܆ Other
܆܆ Drain
܆܆ Pump
܆܆ Other
Spill Container Test Results ܆܆ Pass
܆܆ Fail
܆܆ Pass
܆܆ Fail
܆܆ Pass
܆܆ Fail
܆܆ Pass
܆܆ Fail
1 8. COMMENTS
Describe all answers marked “Other,” “No,” or “Fail” and each proposed remedy.
Performed 1 hour test.
* Mark here if:
Spill containers do not have a minimum capacity of five gallons and require replacement.