HomeMy WebLinkAboutFMC 2022
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
Page 1 of 6
TYPE OF ACTION ☐ Installation ☐ Repair X 12 Month
1. FACILITY INFORMATION
CERS ID
10832560
Certification Date
2/24/2022
Facility Name
OLIVE REFRESH
Facility Address
11206 Olive Dr
City
Bakersfield
ZIP Code
93312
2. SERVICE TECHNICIAN INFORMATION
Company Performing the Certification
Advanced Compliance
Phone
6617064321
Mailing Address
4007 Brae Burn Dr Bakersfield Ca 93306
Service Technician Performing Test
Bradley Hinsley
Contractor/Tank Tester License Number
971259
ICC Number
8373948
ICC Expiration Date
8/9/2023
3. TRAINING AND CERTIFICATIONS
Manufacturer and Test Equipment Training Certifications Expiration Date
ICC Service Techican 8/9/2023
Veeder-root 2/6/2024
Redjacket LLD 5/20/2023
VMI 1/13/2024
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
2/24/2022
Total # of Pages
5. MONITORING SYSTEM AND PROGRAMMING
Underground Storage Tank
Monitoring System Certification Form
Page 2 of 6
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
335.00
Attach the post-certification reports if the monitoring system is capable of generating either;
X Monitoring System Set-up X Alarm History Report Yes No NA
All monitoring equipment is operational per manufacturer’s specifications? X ☐
Secondary containment systems are free of damage, debris, or liquid? X ☐
Are the audible and visual alarms operational? X ☐
All sensors have been: 1) visually inspected for wiring kinks, breaks and residual buildup on
floats; and 2) tested for functionality and confirmed operational? X ☐ ☐
Are all sensors installed to detect a release at the earliest opportunity in the secondary
containment? X ☐ ☐
The monitoring system set-up was reviewed, and proper settings confirmed? X ☐ ☐
Was the monitoring control panel’s backup battery visually inspected, functionally tested,
and confirmed operational? X ☐ ☐
Does the flow of fuel stop at the dispenser if a release is detected in the under-dispenser
containment? X ☐ ☐
Does the turbine automatically shut down if the piping secondary containment monitoring
system fails to operate or is electrically disconnected? X ☐ ☐
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)
X Sump X UDC
X ☐ ☐
If monitoring system alarms are relayed to a remote monitoring center, is all communication
equipment operational? ☐ ☐ X
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
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
L1 208/304 Disp 1/2 X ☐
L2 208/304 Disp 3/4 X ☐
L3 208/304 Disp 5/6 X ☐
L4 208/304 Disp 7/8 X ☐
L5 208/304 Disp 9/10 X ☐
L6 208/304 Disp 11/12 X ☐
L7 208/304 87 STP X ☐
L8 208/304 87 Fill X ☐
L9 208/304 91 STP X ☐
L10 208/304 91 Fill X ☐
L11 208/304 Diesel STP X ☐
L12 208/304 Diesel Fill X ☐
L13 208/304 Vent Pan X ☐
S10 330020-485 87 Product Line X ☐
S11 330020-485 87 Disp return X ☐
S12 330020-485 87 Vent Annular X ☐
S13
330020-485 91 Vent Line
X ☐
S14 330020-485 91 Product Line X ☐
S15 330020-485 Diesel Product Line X ☐
S16 330020-485 Diesel Vent Annular X ☐
☐ ☐
☐ ☐
☐ ☐
☐ ☐
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
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.)
X 3 GPH ☐ 0.1 GPH ☐ 0.2 GPH Yes No NA
Has the testing apparatus been properly calibrated? X ☐ ☐
For emergency generator tank systems, does the LLD create an audible and visual alarm
when a leak is detected? ☐ ☐ X
For mechanical LLDs, does the LLD restrict the flow through the pipe when a release is
detected? X ☐ ☐
For electronic LLDs, does the turbine automatically shut off when a release is detected? ☐ ☐ X
For electronic LLDs, does the turbine automatically shut off if any portion of the monitoring
system is disabled or disconnected? ☐ ☐ X
For electronic LLDs, does the turbine automatically shut off if any portion of the monitoring
system malfunctions or fails a tightness test? ☐ ☐ X
For electronic LLDs, have all accessible wiring connections been visually inspected for
kinks and breaks? ☐ ☐ X
Were all items on the equipment manufacturer’s maintenance checklist completed? X ☐ ☐
Were all LLDs confirmed operational within regulatory requirements? X ☐ ☐
LLD ID LLD Model Lines Monitored Pass Fail
87 FX-1V 87 X ☐
91 FX-1V 91 X ☐
Diesel FX-1DV Diesel X ☐
☐ ☐
☐ ☐
☐ ☐
☐ ☐
☐ ☐
☐ ☐
☐ ☐
☐ ☐
☐ ☐
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
Page 5 of 6
8. IN-TANK GAUGING TESTING
X 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.
208/304 means 794380-208 & 794380-304
10. MONITORING SITE PLAN
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Advanced Compliance
3704 Littlefalls Ct.
Bakersfield, Ca. 93308
661-706-4321 Fax# 661-589-9329
VAPORLESS MANUFACTURING, INC.
LDT-890 Leak Detector Test Record
Contractor: Advanced Compliance Customer: Olive Refresh
Date: 2/24/2022 Location: 11206 Olive Dr. Bakersfield, Ca.
Product: 87 UL Technician: Bradley W. Hinsley
Submersible Pump Identification
Manufacturer: Redjacket Model No.:
Serial No.: Notes:
Leak Detector Identification
Manufacturer: Redjacket Description: FX-1V
Diaphragm-type: Piston-type:
Tamper-proof seal installed: Other Style Leak Detector:
Notes:
Leak Detector in Submersible Pump Test at Dispenser
Operating Pump Pressure (psi): 36 (para. 15)
Gallons per hour rate: 3.0 (para. 22)
Line pressure with pump shut off (psi): 23 (para. 23)
Bleed-back Test with pump off (ml): 115 (para. 26)
Step-through time to full flow (secs): 3 (para. 30)
Leak detector stays in leak search position (Yes/No): Yes (para. 42)
Leak Detector Test
Pass / Fail Notes:
Pass
*Complete thermal expansion test before failing leak detector
Advanced Compliance
3704 Littlefalls Ct.
Bakersfield, Ca. 93308
661-706-4321 Fax# 661-589-9329
VAPORLESS MANUFACTURING, INC.
LDT-890 Leak Detector Test Record
Contractor: Advanced Compliance Customer: Olive Refresh
Date: 2/24/2022 Location: 11206 Olive Dr. Bakersfield, Ca.
Product: 91 UL Technician: Bradley W. Hinsley
Submersible Pump Identification
Manufacturer: Redjacket Model No.:
Serial No.: Notes:
Leak Detector Identification
Manufacturer: Redjacket Description: FX-1V
Diaphragm-type: Piston-type:
Tamper-proof seal installed: Other Style Leak Detector:
Notes:
Leak Detector in Submersible Pump Test at Dispenser
Operating Pump Pressure (psi): 32 (para. 15)
Gallons per hour rate: 3.0 (para. 22)
Line pressure with pump shut off (psi): 20 (para. 23)
Bleed-back Test with pump off (ml): 100 (para. 26)
Step-through time to full flow (secs): 3 (para. 30)
Leak detector stays in leak search position (Yes/No): Yes (para. 42)
Leak Detector Test
Pass / Fail Notes:
Pass
*Complete thermal expansion test before failing leak detector
Advanced Compliance
3704 Littlefalls Ct.
Bakersfield, Ca. 93308
661-706-4321 Fax# 661-589-9329
VAPORLESS MANUFACTURING, INC.
LDT-890 Leak Detector Test Record
Contractor: Advanced Compliance Customer: Olive Refresh
Date: 2/24/2022 Location: 11206 Olive Dr. Bakersfield, Ca.
Product: Diesel Technician: Bradley W. Hinsley
Submersible Pump Identification
Manufacturer: Redjacket Model No.:
Serial No.: Notes:
Leak Detector Identification
Manufacturer: Redjacket Description: FX-1DV
Diaphragm-type: Piston-type:
Tamper-proof seal installed: Other Style Leak Detector:
Notes:
Leak Detector in Submersible Pump Test at Dispenser
Operating Pump Pressure (psi): 36 (para. 15)
Gallons per hour rate: 3.0 (para. 22)
Line pressure with pump shut off (psi): 23 (para. 23)
Bleed-back Test with pump off (ml): 110 (para. 26)
Step-through time to full flow (secs): 3 (para. 30)
Leak detector stays in leak search position (Yes/No): Yes (para. 42)
Leak Detector Test
Pass / Fail Notes:
Pass
*Complete thermal expansion test before failing leak detector
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 X 12 Month
1. FACILITY INFORMATION
CERS ID
10832560
Test Date
2/24/2022
Facility Name
OLIVE REFRESH
Facility Address
11206 Olive Dr
City
Bakersfield
ZIP Code
93312
2. SERVICE TECHNICIAN INFORMATION
Company Performing the Test
Advanced Compliance
Phone
6617064321
Mailing Address
4007 Brae Burn Dr Bakersfield Ca 93306
Service Technician Performing Test
Bradley Hinsley
Contractor/Tank Tester License Number
971259
ICC Number
8373948
ICC Expiration Date
8/9/2023
3. TRAINING AND CERTIFICATIONS
Manufacturer and Test Equipment Training Certifications Expiration Date
ICC Service Techican 8/9/2023
4. TEST PROCEDURE INFORMATION
Test Procedures Used Components Tested
Industry Standard Spill Buckets
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
2/24/2022
Total # of Pages
6. SPILL CONTAINER DETAILS
Test Method Developed by ☐ Manufacturer X Industry Standard ☐ Professional Engineer
Underground Storage Tank
Spill Container Testing Report Form
Additional copies of this page may be attached.
Page 2 of 2
Test Type ☐ Pressure ☐ Vacuum X Hydrostatic
Tank ID 87 91 Diesel
Spill Container Manufacturer: Phil-Tite Phil-Tite Phil-Tite
Method of Cathodic Protection ☐ Nonmetallic
X Other
☐ Nonmetallic
X Other
☐ Nonmetallic
X Other
☐ Nonmetallic
☐ Other
Is the spill container minimum
capacity five gallons excluding riser
volume?
X Yes
☐ No*
X Yes
☐ No*
X Yes
☐ No*
☐ Yes
☐ No*
Method to keep spill container
empty
X Drain
☐ Pump
☐ Other
X Drain
☐ Pump
☐ Other
X Drain
☐ Pump
☐ Other
☐ Drain
☐ Pump
☐ Other
Spill Container Test Results X Pass
☐ Fail
X Pass
☐ Fail
X 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.
Other cathodic protection method is isolation
* Mark here if:
Spill containers do not have a minimum capacity of five gallons and require replacement.