HomeMy WebLinkAbout2022 FMC RepairsAppendix 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
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 Certifi cation
UST Monitoring Site Plan
Site Address: 4101 Truxtun Avenue, Bakersfield, CA. 93301
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Instructions
If you already have a diagram that shows all required information, you may include it, rather than this page, with your Monitoring
System Certification. On your site plan, show the general layout of tanks and piping. Clearly identifl 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 detecton; and in-tank liquid level probes (if used
for leak detection). [n the space provided, note the date this Site Plan was prepared.
Page 4 of 4
rvr w.unidors.orgt \-03(, l/J Rev. 0ll17l0E
t, Ioi
Li'!
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
SHEAR VALVE OPERATION INSPECTION
Facility Name: Owner
Address: Address
City, State, Zip Code: City, State, Zip Code:
Facility I.D. #:Owner Phone #:
Testing Company: Phone #:
This data sheet is for inspecting shear valves located inside dispensers. See PEI/RP1200 Section 10 for the inspection procedure.
Product Grade
Dispenser ID#
Shear ValveType (Product/Vapor)
1. Is the shear valve rigidly
anchored to the dispenser box
frame or dispenser island?
Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No
2. Is the shear section posi-
tioned between ½ inch above
or below the top surface of the
dispenser island?
Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No
3. Is the lever arm free to move?Yes No
NA
Yes No
NA
Yes No
NA
Yes No
NA
Yes No
NA
Yes No
NA
Yes No
NA
Yes No
NA
Yes No
NA
4.Does the lever arm snap the
the poppet valve shut?
Yes No
NA
Yes No
NA
Yes No
NA
Yes No
NA
Yes No
NA
Yes No
NA
Yes No
NA
Yes No
NA
Yes No
NA
5. Can any product be dispensed
when the product shear valve is
closed?
Yes No
NA
Yes No
NA
Yes No
NA
Yes No
NA
Yes No
NA
Yes No
NA
Yes No
NA
Yes No
NA
Yes No
NA
A “No” to Lines 1-4 or a “Yes” for Line 5 indicates a test failure.
Test Results Pass
Fail
Pass
Fail
Pass
Fail
Pass
Fail
Pass
Fail
Pass
Fail
Pass
Fail
Pass
Fail
Pass
Fail
Comments:
Tester’s Name (print) Tester’s Signature
Reference PEI/RP1200-19 Appendix C-10
Date:
Latest Version 3/14/2022
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