HomeMy WebLinkAboutFMC 20182/21/07 1
MONITORING SYSTEM CERTIFICATION
For Use By All Jurisdictions Within the State of California
Authority Cited: Chapter 6.7, Health and Safety Code; Chapter 16, 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 must submit a copy of this form to the local agency regulating UST systems within 30 days of test date.
$General Information
Facility Name: ________________________________________________________________________ Bldg. No.:___________________
Site Address: ________________________________________________ City: ________________________ Zip: ____________________
Facility Contact Person: ___________________________________________ Contact Phone No.: _________________________________
Make/Model of Monitoring System: ________________________________________ Date of Testing/Servicing: ___________________
%Inventory of Equipment Tested/CertifiedCheck the appropriate boxes to indicate specific equipment inspected/serviced:
Tank ID: ____________________________________________
2/21/072
D. Results of Testing/Servicing
Software Version Installed: _____________________________________
Complete the following checklist:
2/21/073
F. In-Tank Gauging / SIR Equipment:
Leak Detector Test Results Sheet
&ĂĐŝůŝƚLJEĂŵĞ͗Site Address:
Test Date:
TechnicianŽŶĚƵĐƚŝŶŐdĞƐƚ: ICC No.:
Product Type LLD Type Model Serial No. Check
Valve
Holding
Pressure
Bleed
Off ML.
Leak
Rate
Tested:
Pass/Fail
3 gph @
10 psi
3 gph @
10 psi
3 gph @
10 psi
3 gph @
10 psi
3 gph @
10 psi
3 gph @
10 psi
3 gph @
10 psi
3 gph @
10 psi
TechnicianSignature: Date:
87 Electronic 849490-00 10 psi 10 ml Pass
91 Electronic 849490-00 10 psi 10 ml Pass
DSL Electronic 849490-00 10 psi 20 ml Pass
08/07/2018
Jaco #7776 Howard's Market 08/07/2018 3300 Planz Road
Aaron Perrigo 8485827-UT
SWRCB, January 2006
Spill Bucket Testing Report Form
This form is intended for use by contractors performing annual testing of UST spill containment structures. The completed form and
printouts from tests (if applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency.
1. FACILITY INFORMATION
Facility Name: Date of Testing:
Facility Address:
Facility Contact: Phone:
Date Local Agency Was Notified of Testing :
Name of Local Agency Inspector (if present during testing):
2. TESTING CONTRACTOR INFORMATION
Company Name:
Technician Conducting Test:
Credentials1: CSLB Contractor ICC Service Tech. SWRCB Tank Tester Other (Specify) __________________
License Number(s):
3. SPILL BUCKET TESTING INFORMATION
Test Method Used: Hydrostatic Vacuum Other
Test Equipment Used: Equipment Resolution:
Identify Spill Bucket (By Tank
Number, Stored Product, etc.)
1234
Bucket Installation Type: Direct Bury
Contained in Sump
Direct Bury
Contained in Sump
Direct Bury
Contained in Sump
Direct Bury
Contained in Sump
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: Pass Fail Pass Fail Pass Fail Pass Fail
Comments –(include information on repairs made prior to testing, and recommended follow-up for failed tests)
CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING
I hereby certify that all the information contained in this report is true, accurate, and in full compliance with legal requirements.
Technician’s Signature:________________________________________________ Date:_________________________
1 State laws and regulations do not currently require testing to be performed by a qualified contractor. However, local requirements
may be more stringent.
Jaco #7776 Howard's Market 08/07/2018
3300 Planz Road
Omero Garcia 661-393-7000
Kris Karns
Confidence UST Services, Inc.
Aaron Perrigo
804904
Lake Test 0.0625"
11.00” 11.00” 11.00”
13.00” 13.00” 13.00”
5 min 5 min 5 min
9:10 9:10
12.75” 12.50”
10:10 10:10
9.75” 11.50”
1 hr 1 hr 1 hr
3.00” 1.00”0.00”
0.0625” 0.0625” 0.0625”
Did not test DSL as the 3.5 gal bucket would not hold 5 gals per Kris Karns, suggest 5 gal Phil-Tite with new riser.
Drain valves on other two buckets would not seat completely as they did in pre-test.
08/07/2018
✔✔
✔
✔✔✔
✔✔✔
87 91 DSL
8485827-UT