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Home My WebLink About2023 EMC (Rejected)Appendix 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 6-1-23 Jaco #3351 Howard's #4 3200 Panama Lane Bakersfield 93313 Nwestco LLC (800) 339-9930 2209 Zeus Court, Bakersfield, CA 93308 Rockland Kirk 1073967 10241356 9-29-24 GVR ATG TECH C32654 9-28-24 6-1-23 5 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-350 336.01 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 (2-1) 208/305 87-1 STP L2 (2-1) 208/305 87-1 FILL L3 (2-1) 208/305 87-2 STP L4 (2-1) 208/305 87-2 FILL L5 (2-1) 208/305 91 STP L6 (2-1) 208/305 91 FILL L7 (2-1) 208/305 DIESEL STP L8 (2-1) 208/305 DIESEL FILL L9 (2-1) 208/305 DISP 1-2 L10 (2-1) 208/305 DISP 3-4 L11 (2-1) 208/305 DISP 5-6 L12 (2-1) 208/305 DISP 7-8 L13 (2-1) 208/305 VENT BOX 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. ܆܆ Performed EMC after 2-1's installed on sit, passed. 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. 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