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Home My WebLink AboutFMC 2022Appendix 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 13 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 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 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 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. Monitoring System Certification UST Monitoring Site Plan Site Address: 1601 Truxtun Avenue, Bakersfield, CA. 93301 □ .'TL� -J,!;·� ovEC?.'-',\\. (:,"�-..:>- :e:'{13qo-� � 1\'lif\lvl�r .:'.>,:i;-Sp r. .' .' ;" ...... . ... 7q�·;5c, -· z.;;,� · :J,..,'I\ p · -;,�n,}o.,. ·�r)(\-/ .. t..,,,� u�. O.ctca"'-'.I ... <! r. Date map was drawn: 06/30/2022Instructions If you already have a diagram that shows all required information, you may include it, rather than this page, with your Monitoring System Ce11ification. On your site plan, show the general layout of tanks and piping. Clearly identify locations of the following equipment, if installed: monitoring system control panels; sensors monitoring tank annular spaces, sumps, dispenser pans, spill containers, or other secondary containment areas; mechanical or electronic line leak detectors; and in-tank liquid level probes (if used for leak detection). In the space provided, note the date th.is Site Plan was prepared. UN-036-4/4 Page 4 of 4 www.unMocs.org Re\'. 01/17/08 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 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. SPILL BUCKET TESTING INFORMATION Test Method Used: Test Equipment Used: Equipment Resolution: Identify Spill Bucket (By Tank Number, Stored Product, etc.) 1 2 3 4 Bucket Installation Type: 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: CVE Cal- Valley Equipment 3500 Gilmore Ave. Bakersfield CA 93308 661 -327-9341 FAX# 661 -325-2529 VAPORLESS MANUFACTURING, INC. LDT-890 Leak Detector Test Record Technician Date Pass / Fail Product Manufacturer Leak rate Operating pressure Line pressure (pump off) Facility Address Bleed back (pump off) Step through time to full flow Stays in leak search position E.. ETEI"1_SETUP JUN 38, :0!2 E:ti_:r SYSTEI,] UI.]1 TS SYSTEI'I LAI']GUAi.;E EI,ICL I EH SYBTEII DarTE T I l'1E FORI{ATl'loN ltr YYtJt/ HH:l.ll"l:EB BXFD CITY POLIIJE DEP I bO l TRUI.ITUI,,I AVE EA}iEREF ] ELT], (:A93i]O 1 661 -826-!BBS EHIFT SHIFT SHIFT SHIFT cor'lr'luNitrATI I'ls lEIUI _ PORT SETTI NGS: FULL \IUL 84. 1 INCH i/ L56.1 It,]L-H ,/OL 28, LJ I I'ICH V(JL I N_TANI( SETUP T i : UI,IL - B? PRDDUCT COTIE THERi"IAL LTOEFF TAN}i DI AT,]ETEE TANH PROF t LE 1 .0rlLrE?0112.13.I PTS l4?83 11?61 EBOB:5 09 l:r0t" 't EOAR!r EAUTJ RATE PiiR I TY STOF EIT TIATA LENGTH I t Fi(:t'l0tr ) 2q 00 ODDt ETOP7 DATfl FLll*T EIEE: 4.LL Il'1. HHTEE l'IAENlllG : 3'l] HI(]H UJHTER LII"IIT: 5'I 1lf,lE ITIIIE : T] I]E :'tiHE 4 T,I SHELED TI I EHELED D IEAELE[T D I SAELED TFiT l,lEEtrEIr [iPll TST IIEEITEI I,,lEl,l RS-EBI gEf,UR I T'r' CODE : D I EAELET)DIAL TVPE : TONEANSUERON:lRINfJ MODEI.I SETUP STR I I']G : D I AL TONE I I'ITERVAL : 32 RECEIVER SETL]P : NONE I.]A:{ OE LITEEL VOL OUEFFILL LI T1I T HIGH !'EODULIT T]ELIVERY LII.lIT LOI,I PROTIUCT LE*H ALTTRI,I LI I'1I T SUDIEI.] LOEE LII'1IT : TANX TILT : PROBE OFFSET : 14?8: lE% 1 {0n jglti I :1lrl4llr, 0 1l 99 :-r ! D.oLl 0. LtD THlll: PER I) I SAELETT TAI,IH Af,,]II I] ] SAELED L I I,lE EE EI{HELE |IETHOD },HES LII,IE TEET L]NE PEE D I SAELED L I I.IE ANN T] I SAELET] TET I,]EEIEII 1"]FI1 T5T I'IEETTET] LJRI{ PR I NT TC VOLUI,IES EI{AELED TE|"IP COl.lPENSrrTlOll VALUE (I]EG F ): 6I].I:I ET ICI{ HEIGHT OFFSET D ISAELED H_PROTOCOL T]ATA FOEI"]HT HE I EHT DAVLIGHT SAVI I,,]'.; T I f.,]E E I,{ABLED START DATEAPR I,]EEX 1 9UI,,1STAFT T I I,IE3:00 flt,l END TIATEOCT I'EEX b SUN END T IT,IE 2 : tto At"l RE-DI RE[)T LSCAL PRI I'I OUT DI SABLED EURO PFOTICNL PEEF I X S SYSTEI.I SE(]UF I TY[oDE:0000t:i[ .-:USTOI'] ALARI.'I Lfi EELFJ D I SAELED AUTO TT I AL T I I'lE SETUP : NONE ES-T32 EI,ID OF I"IESSAGE DI SAELED tulo_Li*! ALARr'1_sEruP E I FHOI,I I,1AI.1] FI)LI]EIT TANHSTB: NOI'IE LtNE I.1ANI FOLDEIT TANKE TS: tiONE LEA}I I'1IN PEEIOITII: : LEAI{ l'll I'1 Hl'll'lLIHL : PERIODIT:r TEST TYPE STANTIARO ANNUAL TEST FAIL ALARI'] D I SHELED PEEIO!IC TEST FAIL ALAEI,] g I S*ELEI] GROSS TEST FAI L ALARI,I tJ I SAELED AIiI.I TEST AVERA'J i NG : OFF PEE TEST AVERA(JI I'IG: OFF TAI'I}: TEST I,IOT I FY : OFF Tl,lH TET E I PH{ltl EREA}: :OfF DELI VEEY DELAY : I I"1I I\] PUI"IP THREEHOLTI : l O. OO% _11; D ,1", U LEAl{_rESrlErlo!,_-_ TEST ON I)HTE : ALL TAI.IX r"10v 10. 2003 BTART TIf'IE : TIISiTELED TEST RATE :0.28 GAL. HE DUEATIT}N : 2 HOURS TST EARLY ST P:DI SABLEI) LE*}i TEST REPOET FORI"IAT NORI.lAL UUTPIJT RELI1Y SETUP R I : REI'I{)TE HLERl,l GHRH(_;E TYPE : STHNDHRI) I!i]RI']ALLY OPEI,I I II-TAN}i AL*KI"]ET 1 :LEfiI1 HLBRHT l:HIaiH IJHTER HL.iRI"lT I :OVEFFILL HLAEt"lT I : LOI,j PRODUCT ALITPI.IT I :SUDDEN LOSS ALARI'IT 1:HIGH PRODUI)T *LHRIIT 1 :PROEE UUT : HIGH NATER LNAFNIT.]G : DEL I VERY I.IEEDED:llAX PROtiUr:lT ALAEl,l:GFOSS TEST FAIL Lr 6u r D_sEr,rsoR-slrlP _ _ _ L I:PIF'ING SUI.1P SEI.]|JOR TRI-ETATE (SI I,t{.iLE FLOAT} L]ATEGOEI/ : OTHER SENSORFJ L ? : AIINULAR gPACE FJEI"ISORTRI.STATE (SI NGLE FLOAT ) CATEGORV : OTHEE EEI']SOES T T T T LIOUI D EEI']Fi0F pLI,lFi HLL :FLIEL ALITRI.IALL :SENSOE O.]T i.1LAFI"IALL :EHORT HLIIRI'I ALL : Ii]ATER AL*8I.1 ALL : LiJATER OUT ALARl"l ALL : HIIIH LISUIIT HLARI'I ALL :LOI,,I LIAUIL HLARI"I ALL :LIOUITI I,JARII I NG R 3 :FUEL LEA].: STAI,JT)ARD I,.INRTI*LLY CLIJSED L]OUID SEI'IEOF ALI.1S ALL : FUEL I.ILARI'I ALL:EENEOR OUT AL*EI'I*LL : SH+ET Ht-ARi'I E 4 :OUTS I DE iiLARI.l TYT,E: ST*ITIiRD r'toRtlALLY O!,Et,l I I,I-T*I.]K ALARI,]E ALL : LEAH ALI+RI"IALL:HIGH UTiTER HLHEl"l ALL:OVERFI LL HLHRI'IiiLL I LOL,J F'RODULTT rlLARl"l HLL :FJUDI]EN LI]ES ALAFI.IT 1:HIGH PE{]I,U'.]T ALARI'IALL:FFOEE OUT r.iLL:HIGH l,lATER LiARNI l,lLjALL:DELIVERY NEEDETIT I :flAX F'RODIJL::T ALHRl"lT I :GEOSS TEST FfiIL L I8U I D SEI'ISOF IILI']D- ALL :FUEL ALARI"] ALL:EENEoE oUT ALnEI,l ALL:SHORT ALHRt"l IILL :I.]ATER ALHRI.IiiLL:UATER OUT fil.aEl.lALL:HIGH LI6UItT ALAEI']ALL:LOh LIOUID HLARI"] TLL: L I6UI D I,IARI,JI I"](] f,B[3l^j![.155"1?r0H LE'/EL soFrr,JHRE;-ji;:!4_ I DD_ELXEH I rJ,r _ DJ.l l.lu. t?,15 I{O SOFTL^JiiRE r,ra)rrlrr FSTETEH FEATUR'ii.-- Ii[,ili' \,, ] i;ili,,f ,"IiB'= ALARI.I HISTOFY REPOFT ----- EYETEil gLAFr"t ----- PAPEE NUTAPF 6, t022 E: !6 PRI NTEE EFEOFAPR 6, 202.J E : 2E EATTEFY IF OFF NOV 10, PO[3 B:02 *LAFI,I HIETOFI",' REFNRT .''.- SENSNR ALARI.I -_L 1:! IFll\lc SUI1P sEf'lsllFl OTHER EEI,]ENRB EEI,]SOH OUT ILARI,] FUEL ALARI,IFEB 4. Et_rt1 9:[B EENEOE flUT ALITFI']FEE 13, 1020 L0:18 xrix*lEl,lLrxari AL.TEI'] HIETORY EEPONT ---- I I'l-TAI,tX AL Rr.1 ----- T 1 : UNL_ST SETUP DATA I'IARN I NG JAN l9.2DlS 9:30 OVERF I LL ALARI'1 FEE I3, ?DEO 1O:12JUN 9, 2trE4 l3:04 APR IE, EOO4 ?:07 LOH PEOIIUCT ALARI,] JAN 19, ?018 9:30 H I IJH PRODUIJT ALARI'] DEC 17, 20?t 14:31Nov 29, 2021 10:26 FEE I3, ?OzE IO:1P PEOEE OUT FEE 13,2020 I [:09JUL 5, e0t9 20:!9JUL 5, 201 9 ?0:28 LOU TEI.1P IiJARN I IIGFEE 13, E0?tl 10:10JIJL 5, 201 I 20 : 27NOV 5, 2812 9:28 ALAEI.I HISTORV REPORT -___- BENSOE ALAR[,] _---_ L 2 : AIINULAR SPACE EEI,JSOR OTHEF SENSOES SENSOE OUT ALAET1FEE 4, 20Et 9:29 FUEL ALARI'IFEE 4,2021 9: E9 FUEL ALARI4FEB 4, 2021 E:35 *tx**EI,l[r)i*l'x;i xxlitxEl',lI)1,{ix;{ XtX*r(El,ltl:ri}rx