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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: Regular Mechanical FX1V 28 psi 100 ml Pass Premium Mechanical FX1V 30 psi 110 ml Pass Diesel Mechanical FX1DV 32 psi 130 ml Pass 07/23/2018 Jaco #7785 Fastrip #32 07/23/2018 3701 Ming Avenue Austin Sterling 8339953 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 #7785 Fastrip #32 07/23/2018 3701 Ming Avenue Omero Garcia 661-393-7000 6-8-2018 Confidence UST Services, Inc. Austin Sterling 804904 Lake Test 0.0625" 12.00"12.00" 12.00" 12.00" 12.00" 12.00" 5 min 5 min 5 min 9:45 am 9:45 am 9:45 am 8.25"8.50 "8.50" 10:45 am 10:45 am 10:45 am 8.25" 8.50" 8.50" 1 hour 1 hour 1 hour 0.00" 0.00" 0.00" 0.0625" 0.0625" 0.0625" 07/23/2018 ✔✔ ✔ ✔✔✔ ✔✔✔ Regular Premium Diesel 8339953