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Home My WebLink About2022 FMCAppendix 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 Certification Date Facility Name Facility Address City ZIP Code 2. SERVICE TECHNICIAN INFORMATION Company Performing the Certification Phone Mailing Address Service Technician Performing Test Contractor/Tank Tester License Number ICC Number ICC Expiration Date 3. TRAINING AND CERTIFICATIONS Manufacturer and Test Equipment Training Certifications Expiration Date 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 Total # of Pages 10134208 4/27/22 Jaco #3351 Howard's #4 3200 Panama Lane Bakersfield 93313 Nwestco LLC (800) 339-9930 2209 Zeus Court, Bakersfield, CA 93308 Payton Phillips 1073967 9482312 1/15/24 Veedor Root C27796 7/29/22 4/27/22 7 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 Model of Monitoring System Control Panel Software Version Installed 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 Veedor Root TLS-350 335.00 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 ܆܆ ܆܆ ܆܆ ܆܆ ܆܆ ܆܆ ܆܆ ܆܆ ܆܆ ܆܆ ܆܆ ܆܆ ܆܆ ܆܆ ܆܆ ܆܆ ܆܆ ܆܆ ܆܆ ܆܆ ܆܆ ܆܆ ܆܆ ܆܆ ܆܆ ܆܆ ܆܆ ܆܆ ܆܆ ܆܆ ܆܆ ܆܆ ܆܆ ܆܆ ܆܆ ܆܆ ܆܆ ܆܆ ܆܆ ܆܆ ܆܆ ܆܆ ܆܆ ܆܆ ܆܆ ܆܆ ܆܆ ܆܆ Describe all answers marked “No” or “Fail” and proposed remedy in Section 9. List all monitoring equipment either replaced or repaired in Section 9 L1 208 / 304 87-1 STP L2 208 / 304 87-1 Fill L3 208 / 304 87-2 STP L4 208 / 304 87-2 Fill L5 208 / 304 91 STP L6 208 / 304 91 Fill L7 208 / 304 Diesel STP L8 208 / 304 Diesel Fill L9 208 / 304 Disp 1-2 L10 208 / 304 Disp 3-4 L11 208 / 304 Disp 5-6 L12 208 / 304 Disp 7-8 L13 208 / 304 Vent Box S1 330020-464 87-1 Product S2 330020-464 87-1 Vent S3 420 87-1 Tank S4 330020-464 87-2 Product S5 330020-464 87-2 Vent S6 420 87-2 Tank S7 330020-464 87-2 Vapor S9 330020-464 91 Product S10 330020-464 91 Vent S11 420 91 Tank S12 330020-464 Diesel Product 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 ܆܆ ܆܆ ܆܆ ܆܆ ܆܆ ܆܆ ܆܆ ܆܆ ܆܆ ܆܆ ܆܆ ܆܆ ܆܆ ܆܆ ܆܆ ܆܆ ܆܆ ܆܆ ܆܆ ܆܆ ܆܆ ܆܆ ܆܆ ܆܆ ܆܆ ܆܆ ܆܆ ܆܆ ܆܆ ܆܆ ܆܆ ܆܆ ܆܆ ܆܆ ܆܆ ܆܆ ܆܆ ܆܆ ܆܆ ܆܆ ܆܆ ܆܆ ܆܆ ܆܆ ܆܆ ܆܆ ܆܆ ܆܆ Describe all answers marked “No” or “Fail” and proposed remedy in Section 9. List all monitoring equipment either replaced or repaired in Section 9 S13 330020-464 Diesel Vent S14 420 Diesel Tank 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 Q1 PLLD 87:Unleaded Q2 PLLD 91 Premium Q3 PLLD Diesel 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. 4/10/2020 STP PROPERTY LINE NO PARKING 4 3 8 7 65 21 STP STP STP F F F FV V V 12,000 GALLON87-1 UNLEADED 12,000 GALLON87-2 UNLEADED 12,000 GALLONPREMIUM 12,000 GALLONDIESEL H PANAMA LN. W I B L E R D . EXISTING BUILDING W CATCHBASIN PRI C E S I G N DUMPSTER GATED ENCLOSURE WITHA STAND ALONE ROOF PROPERTY LINE N V-GUTTER SWITCHGEAR 87 GAS 1.5" OMEGAFLEX PIPE 91 GAS 1.5" OMEGAFLEX PIPE DIESEL 1.5" OMEGAFLEX PIPE VAPOR RETURN 3/2 INCH DBL WALL PIPE VAPOR RETURN 3/2 INCH MANIFOLDS VAPOR RETURN 4/3 INCH DBL WALL PIPE VAPOR VENT 3/2 INCH DBL WALL PIPE VACUUM CROSSOVER 3/2 DBL WALL PIPE PRODUCT SPILL CONTAINER VAPOR SPILL CONTAINER EMERGENCY SHUT-OFF OVERFILL ALARM FIRE EXTINGUISHER WATER SHUT OFF HEALY CAS EVACUATION MEETING POINT AUTOMATIC TANK GAUGE UST ELECTRICAL PANEL CIRCUIT BREAKER AIR AND WATER DISPENSER HAZWASTE DRUM H F V W S1 87-1 PRODUCT LINE SMART SENSOR S2 87-1 VENT LINE SMART SENSOR S3 87-1 TANK ANNULAR SMART SENSOR S4 87-2 PRODUCT LINE SMART SENSOR S5 87-2 VENT LINE SMART SENSOR S6 87-2 TANK ANNULAR SMART SENSOR S7 87-2 VAPOR LINE SMART SENSOR S8 TEMPERATURE SENSOR METER S9 PREMIUM PRODUCT SMART SENSOR S10 PREMIUM VENT LINE SMART SENSOR S11 PREMIUM TANK ANNULAR SMART SENSOR S12 DIESEL PRODUCT SMART SENSOR S13 DIESEL VENT LINE SMART SENSOR S14 DIESEL TANK ANNULAR SMART SENSOR LEGEND L1 87-1 STP SUMP L2 87-1 FILL SUMP L3 87-2 STP SUMP L4 87-2 FILL SUMP L5 PREMIUM STP SUMP L6 PREMIUM FILL SUMP L7 DIESEL STP SUMP L8 DIESEL FILL SUMP L9 UDC 1-2 L10 UDC 3-4 L11 UDC 5-6 L12 UDC 7-8 L13 VENT BOX DATE: DRAWN BY: CHECKED: APPROVED: RAC FASTRIP - 3351 CADFILE: SHEET NO.3351-MSP HOWARD'S MINI MARKETCONVENIENCE MARKET FOR: BAKERSFIELD, CALIFORNIA 933133200 PANAMA LN. DRAWING: DATE REVISIONS A.P.N.: 372-021-33 SCALE: JACO HILL3101 STATE RDBAKERSFIELD, CA 93308 PROJECT OWNER: CD SITE MAP SITE PLAN C1 VICINITY MAP TAB:CERS 1/8"=1'-0" 0 SHEET SIZE 22 X 34 3200 PANAMA LN.BAKERSFIELD, CA 93313 PROJECT OWNER: JACO HILL PO. BOX 82515 BAKERSFIELD, CA 93380 CONTACT: SITE PLOT PLAN FOR: FACILITY ID 15-021-46941 CERS ID 10134208 FASTRIP #3351 3200 PANAMA LN. BAKERSFIELD, CA 93313 03/01/2021 REV. W I B L E R D . PANAMA LN. 03/01/2021 PROJECT DATA 5'10'15' 20' L1,S1,S2,S3 L2 L3,S4,S5,S6,S7 L4 L5,S9,S10,S11 L6 L7,S12,S13,S14 L8 L11 L9 L10 L12 VAPOR MANIFOLDCAPPED L13 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 Test Date Facility Name Facility Address City ZIP Code 2. SERVICE TECHNICIAN INFORMATION Company Performing the Test Phone Mailing Address Service Technician Performing Test Contractor/Tank Tester License Number ICC Number ICC Expiration Date 3. TRAINING AND CERTIFICATIONS Manufacturer and Test Equipment Training Certifications Expiration Date 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 Total # of Pages 10134208 4/27/22 Jaco #3351 Howard's #4 3200 Panama Lane Bakersfield 93313 Nwestco LLC (800) 339-9930 2209 Zeus Court, Bakersfield, CA 93308 Payton Phillips 1073967 9482312 1/15/24 FFS 1016783712 5/25/23 Hydrostatic Lake Test EBW Spill Buckets 4/27/22 2 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 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 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. * Mark here if: Spill containers do not have a minimum capacity of five gallons and require replacement. T1 87-1 EBW T2 87-2 EBW T3 91 EBw T4 Diesel EBW