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Appendix 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
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TYPE OF ACTION ☐☐☐☐Installation ☐☐☐☐Repair XXXX12 Month
1. FACILITY INFORMATION
CERS ID
10023799
Certification Date
11/24/2020
Facility Name
Cirlce K
Facility Address
1030 Oak St.
City
Bakersfield
ZIP Code
93304
2. SERVICE TECHNICIAN INFORMATION
Company Performing the Certification
B&T Service Station Contractors
Phone
805-929-8944
Mailing Address
630 S. Frontage Rd. Nipomo, CA 93444
Service Technician Performing Test
Michael A. Molacek
Contractor/Tank Tester License Number
902034
ICC Number
9175943
ICC Expiration Date
11/15/2021
3. TRAINING AND CERTIFICATIONS
Manufacturer and Test Equipment Training Certifications Expiration Date
Veeder Root TLS 350 Technician C27901 10/29/2022
VMI Catastrophic Testing Technician 4640 04/06/2022
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
11/24/2020
Total # of Pages
5. MONITORING SYSTEM AND PROGRAMMING
Underground Storage Tank
Monitoring System Certification Form
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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
334.01
Attach the post-certification reports if the monitoring system is capable of generating
either;XXXXMonitoring System Set-up XXXXAlarm History Report Yes No NA
All monitoring equipment is operational per manufacturer’s specifications? XXXX ☐☐☐☐
Secondary containment systems arefree of damage, debris, or liquid? XXXX ☐☐☐☐
Are the audible and visual alarms operational? XXXX ☐☐☐☐
All sensors have been: 1) visually inspected for wiring kinks, breaks andresidual buildup on
floats; and 2) tested for functionality and confirmed operational? XXXX ☐☐☐☐ ☐☐☐☐
Are all sensors installed to detect a release at the earliest opportunity in the secondary
containment? XXXX ☐☐☐☐ ☐☐☐☐
The monitoring system set-up was reviewed,and proper settings confirmed? XXXX ☐☐☐☐ ☐☐☐☐
Was the monitoring control panel’s backup battery visually inspected, functionally tested,
and confirmed operational? XXXX ☐☐☐☐ ☐☐☐☐
Does the flow of fuel stop at the dispenser if a release is detected in the under-dispenser
containment? XXXX ☐☐☐☐ ☐☐☐☐
Does the turbine automatically shut down if the piping secondary containment monitoring
system fails to operate or is electrically disconnected? XXXX ☐☐☐☐ ☐☐☐☐
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)XSump ☐UDC
XXXX ☐☐☐☐ ☐☐☐☐
If monitoring system alarms are relayed to a remote monitoring center, is all communication
equipment operational? XXXX ☐☐☐☐ ☐☐☐☐
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
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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
L1 409 87 Annular XXXX ☐☐☐☐
L2 409 91 Annular XXXX ☐☐☐☐
L3 409 89 Annular XXXX ☐☐☐☐
L7 208 87 Fill Sump XXXX ☐☐☐☐
L8 208 91 Fill Sump XXXX ☐☐☐☐
L9 208 89 Fill Sump XXXX ☐☐☐☐
S1 Mag Sensor 87 Turbine XXXX ☐☐☐☐
S2 Mag Sensor 91 Turbine XXXX ☐☐☐☐
S3 Mag Sensor 89 Turbine XXXX ☐☐☐☐
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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
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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.)
XXXX3 GPH ☐☐☐☐0.1 GPH☐☐☐☐0.2 GPH Yes No NA
Has the testing apparatus been properly calibrated? XXXX ☐☐☐☐ ☐☐☐☐
For emergency generator tank systems, does the LLD create an audible and visual alarm
when a leak is detected? ☐☐☐☐ ☐☐☐☐ XXXX
For mechanical LLDs, does the LLD restrict the flow through the pipe when a release is
detected? XXXX ☐☐☐☐ ☐☐☐☐
For electronic LLDs, does the turbine automatically shut off when a release is detected? ☐☐☐☐ ☐☐☐☐ XXXX
For electronic LLDs, does the turbine automatically shut off if any portion of the monitoring
system is disabled or disconnected? ☐☐☐☐ ☐☐☐☐ XXXX
For electronic LLDs, does the turbine automatically shut off if any portion of the monitoring
system malfunctions or fails a tightness test? ☐☐☐☐ ☐☐☐☐ XXXX
For electronic LLDs, have all accessible wiring connections been visually inspected for
kinks and breaks? ☐☐☐☐ ☐☐☐☐ XXXX
Were all items on the equipment manufacturer’s maintenance checklist completed? XXXX ☐☐☐☐ ☐☐☐☐
Were all LLDs confirmed operational within regulatory requirements? XXXX ☐☐☐☐ ☐☐☐☐
LLD ID LLD Model Lines Monitored Pass Fail
T1 LD 2000 87 XXXX ☐☐☐☐
T2 LD 2000 89 XXXX ☐☐☐☐
T3 LD 2000 91 XXXX ☐☐☐☐
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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
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8. IN-TANK GAUGING TESTING
XXXXCheck 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
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9. COMMENTS
10. MONITORING SITE PLAN
Describe all answers marked “No” or “Fail” and proposed remedy.
List all monitoring equipment either replaced or repaired.