HomeMy WebLinkAboutFMC 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.) Building #
Business Site Address City
ZIP Code
II. UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION
Name of Company Performing the Certification
Phone # ( ) - Ext.
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
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 any 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
--------------- -----��-·
Monitoring System Certification
UST Monitoring Site Plan
Site Address: 1601 Truxtun Avenue, Bakersfield, CA. 93301
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Instructions
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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 tan.ks 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.
UN-036-4/4
Page 4 of 4
www.unidocs.org Rev. 01/17/08
02 13 20
CERS = California Environmental Reporting System, ID = Identification, UST = Underground storage tank, ICC = International Code Council
UNDERGROUND STORAGE TANK SPILL CONTAINER TESTING REPORT FORM (Page 1 of 1)
Type of Action Installation Test Repair Test 12 Month Test
I. FACILITY INFORMATION
CERS ID
Date of Spill Container Test
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 UST Service Technician Performing the Test (Print as shown on the ICC Certification.)
Phone # ( ) - Ext.
Contractor/Tank Tester License #
ICC Certification #
ICC Certification Expiration Date
Spill Container Testing Training and Certifications (List applicable certifications.)
III. SPILL CONTAINER TESTING INFORMATION
Test Method Used:
Manufacturer Guidelines: (Specify)
Industry Code or Engineering Standard: (Specify)
Engineered Method: (Specify)
Attach the testing procedures and all documentation required to determine the results. # of Attached Pages
Tank ID: (By tank number, stored product, etc.)
Spill Container Manufacturer:
Method of Cathodic Protection
Non-Metallic Non-Metallic Non-Metallic Non-Metallic
Isolation Isolation Isolation Isolation
Other (Specify in section V.) Other (Specify in section V.) Other (Specify in section V.) Other (Specify in section V.)
Inside Diameter of Spill Container: (Inches)
Depth of Spill Container: (Inches)
Does the spill container have a 5 gallon capacity? Yes No Yes No Yes No Yes No
Method to Keep Spill Container Empty
Drain Valve Drain Valve Drain Valve Drain Valve
Onsite Pump Onsite Pump Onsite Pump Onsite Pump
Other
(Specify in section V.) Other
(Specify in section V.) Other
(Specify in section V.) Other
(Specify in section V.)
IV. SUMMARY OF TESTING RESULTS
Spill Container Test Results Pass Fail Pass Fail Pass Fail Pass Fail
V. COMMENTS
All items marked “Fail” above must be explained in this section. Any additional comments may also be provided here.
VI. CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS TESTING
I hereby certify that the spill containers were tested in accordance with California Code of Regulations, title 23, division 3, chapter 16, section 2637.1 and all the information contained herein is accurate.
UST Service Technician Signature
If the facility has more components than this form accommodates, additional copies of this page may be attached.
SPILL BUCKET TESTING INFORMATION
Test Method Used:
Test Equipment Used: Equipment Resolution:
Identify Spill Bucket (By Tank Number, Stored Product, etc.) 1 2 3 4
Bucket Installation Type:
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:
CVE
Cal- Valley Equipment
3500 Gilmore Ave.
Bakersfield CA 93308
661 -327-9341 FAX# 661 -325-2529
VAPORLESS MANUFACTURING, INC.
LDT-890 Leak Detector Test Record
Technician Date
Pass / Fail
Product
Manufacturer
Leak rate
Operating pressure
Line pressure (pump off)
Facility Address
Bleed back (pump off)
Step through time to full flow
Stays in leak search position
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