HomeMy WebLinkAboutFMC 2023Appendix 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.
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.
Leak Detector
FXT EVALUATION CHART
Site Location ________________________________Service Company ___________________________________
________________________________________________________________________________________________
Date ____________________
Technician Performing Test _______________________________________________
TECH Number ____________________
TYPES OF LEAK DETECTORS TESTED
BFLD (117-182-5)FX2V (116-057-5)FX2DV (116-059-5)
FX1V (116-056-5)FX1DV (116-058-5)
TEST INFORMATION
Product
Serial
Number
Opening
Time
Metering
psi/kPa
Pressure Relief
Holding
psi/kPa
Approximate
Test Leak Rate
ml/Min
gph
Pass/Fail
Test Leak Rate
ml/Min
gph
Pump
psi/kPa
Pressure
1
2
3
4
5
6
7
8
Owner/Operator
_____________________________________________________________________________________________
(Signature)(Date)
WORLD OIL BSSR, INC
1850 COFFE RD 6630 ROSEDALE HWY, SUITE B
3/30/23
NATHAN HOLMAN
B40744
116-058 3 SEC 20 PSI 10 PSI 3 GPH PASS 25 PSI
3/30/23
Appendix VIIIUnderground 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
✔
3/30/23
WORLD OIL
1850 COFFEE RD BAKERSFIELD 93308
BSSR INC 661-588-2777
6630 ROSEDALE HWY
NATHAN HOLMAN
672812
8111067 8/22/24
OPW 10/20/24
1 HR HYDROSTATIC DIESEL FILL BUCKET
3/30/23
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 DSL
OPW
✔
✔
✔
✔
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APPENDIX C-10
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