HomeMy WebLinkAbout2022-04-27 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.WIBLE RD.EXISTING BUILDING
W
CATCHBASINPRICE SIGNDUMPSTER
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.WIBLE RD.
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