HomeMy WebLinkAbout2022 FMC RESULTSAppendix 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
10155965 09-27-2022
Jaco #5562 Fastrip #6
1640 South Chester Avenue Bakersfield 93304
Nwestco LLC (800) 339-9930
2209 Zeus Court, Bakersfield, CA 93308
Ronald Clark
1073967
9482314 05-04-2024
Veeder Root C27795 08-29-2024
09-27-2022 8
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
Veeder Root TLS-350 336.02
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 794380-208 UNL 1 STP
L2 794380-420 UNL 1 ANN
L3 794380-208 DIESEL STP
L4 794380-420 DIESEL ANN
L5 794380-208 PNL STP
L6 794380-420 PNL ANN
L7 794380-208 UNL 2 SIPON STP
L8 794380-420 UNL 2 ANN
L9 794380-208 DISP 1-2
L10 794380-208 DISP 3-4
L11 794380-208 DISP 5-6
L12 794380-208 DISP 7-8
L13 794380-208 TRANS NO
L14 794380-208 TRANS SO
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
Unleaded FX1V Both unleaded lines
Premium FX1V Premium
Diesel FX1DV 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.
NOPARKING
ASTPL5
STPL3
STPL1
STPL7
12,000 GALLON87-1 UNLEADED
12,000 GALLON87-2 UNLEADEDSIPHON
12,000 GALLONDIESEL
12,000 GALLON91 PREMIUM VF L6
F A
V
L4
AF
L13
L2
VF AL8
L10 L12
L11L9
L14
12 56
7 834
EXISTING BUILDING
GHW
PROPERTY LINE
CHESTER AVE MING AVEPROPERTY LINEN
CATCHBASINPRICE SIGN40' STORAGE CONTAINERDUMPSTER
ALLEYALLEY
LEGEND
L1 87-1 STP
L2 87-1 ANNULAR
L3 DSL STP
L4 DSL ANNULAR
L5 91 STP
L6 91 ANNULAR
L7 87-2 SIPHON STP
L8 87-2 ANNULAR
L9 UDC 1 - 2
L10 UDC 3 - 4
L11 UDC 5 - 6
L12 UDC 7 - 8
L13 N TRANS SUMP
L14 S TRANS SUMP
87 GAS 3/2 INCH DBL WALLED PIPE
91 GAS 3/2 INCH DBL WALLED PIPE
DIESEL 3/2 INCH DBL WALLED PIPE
VAPOR RETURN 3 AND 2 INCH SINGLE WALL PIPE
VAPOR VENT 2 INCH SINGLE WALLED PIPE
PRODUCT SPILL CONTAINER
VAPOR SPILL CONTAINER
ANNULAR
EMERGENCY SHUT-OFF
OVERFILL ALARM
FIRE EXTINGUISHER
GAS METER SHUT-OFF
HEALY CAS
EVACUATION MEETING POINT
CIRCUIT BREAKER
UST ELECTRICAL PANEL
AUTOMATIC TANK GAUGE
AIR AND WATER DISPENSER
HAZWASTE DRUM
G
A
H
P
V
SITE MAP
PROJECT OWNER:
JACO HILL
PO. BOX 82515
BAKERSFIELD, CA 93308
CONTACT:
SITE PLOT PLAN FOR:
FACILITY 015-021-002928
CERS 10155965
FASTRIP #5562
1640 S CHESTER AVE.
BAKERSFIELD, CA 93304
10/24/16 REV.
C1
VICINITY MAP
PROJECT DATA
1"=10'-0"
INCHES012
SHEET SIZE 22 X 34
SCALE:
1640 S CHESTER AVE.
BAKERSFIELD, CA 93304
S CH
ES
T
ER
AVE
MING AVE
APPENDIX C-10
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APPENDIX C-10
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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
10155965 09-27-2022
Jaco #5562 Fastrip #6
1640 South Chester Avenue Bakersfield 93304
Nwestco LLC (800) 339-9930
2209 Zeus Court, Bakersfield, CA 93308
Ronald Clark
1073967
9482314 05-04-2024
OPW 0187329 08-31-2024
Hydrostatic Spill buckets
09-27-2022 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
OPW
T2 91
OPW
T3 DSL
OPW
T4 87(2)
OPW