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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
10023058
Certification Date
7/6/2023
Facility Name
ARCO White Ln.
Facility Address
6450 White Ln.
City
Bakersfield
ZIP Code
93309
2. SERVICE TECHNICIAN INFORMATION
Company Performing the Certification
Advanced Compliance
Phone
661-706-4321
Mailing Address
4007 Brae Burn Dr Bakersfield Ca. 93306
Service Technician Performing Test
Bruce W. Hinsley
Contractor/Tank Tester License Number
971259
ICC Number
8032698
ICC Expiration Date
6/23/2025
3. TRAINING AND CERTIFICATIONS
Manufacturer and Test Equipment Training Certifications Expiration Date
Veeder-Root 3/19/2024
VMI 1/18/2024
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
7/6/2023
Total # of Pages
5. MONITORING SYSTEM AND PROGRAMMING
A separate Monitoring System Certification Form must be prepared for each control panel.
Make of Monitoring System
Control Panel
Veeder-Root
Model of Monitoring System
Control Panel
TLS-350
Software Version Installed
131.00
Attach the post-certification reports if the monitoring system is capable of generating either;
X Monitoring System Set-up X Alarm History Report Yes No NA
All monitoring equipment is operational per manufacturer’s specifications? X ☐
Secondary containment systems are free of damage, debris, or liquid? X ☐
Are the audible and visual alarms operational? X ☐
All sensors have been: 1) visually inspected for wiring kinks, breaks and residual buildup on
floats; and 2) tested for functionality and confirmed operational? X ☐ ☐
Are all sensors installed to detect a release at the earliest opportunity in the secondary
containment? X ☐ ☐
The monitoring system set-up was reviewed, and proper settings confirmed? X ☐ ☐
Was the monitoring control panel’s backup battery visually inspected, functionally tested,
and confirmed operational? X ☐ ☐
Does the flow of fuel stop at the dispenser if a release is detected in the under-dispenser
containment? X ☐ ☐
Does the turbine automatically shut down if the piping secondary containment monitoring
system fails to operate or is electrically disconnected? X ☐ ☐
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)
X Sump X UDC
X ☐ ☐
If monitoring system alarms are relayed to a remote monitoring center, is all communication
equipment operational? ☐ ☐ X
Describe all answers marked “No” or “Fail” and proposed remedy in Section 9.
List all monitoring equipment either replaced or repaired in Section 9
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
L-1 794390-409 87 Main Annular X ☐
L-2 794380-208 87 Main Fill Sump X ☐
L-3 794380-208 87 Main STP Sump X ☐
L-4 794390-409 87 Aux Annular X ☐
L-5 794380-208 87 Aux Fill Sump X ☐
L-6 794380-208 87 Aux STP Sump X ☐
L-7 794390-409 91 Annular X ☐
L-8 794380-208 91 Fill Sump X ☐
L-9 794380-208 91 STP Sump X ☐
L-10 794380-208 UDC 1-2 X ☐
L-11 794380-208 UDC 3-4 X ☐
L-12 794380-208 UDC 5-6 X ☐
L-13 794380-208 UDC 7-8 X ☐
L-14 794380-208 UDC 9-10 X ☐
L-15 794380-208 UDC 11-12 X ☐
☐ ☐
☐ ☐
☐ ☐
☐ ☐
☐ ☐
☐ ☐
☐ ☐
☐ ☐
☐ ☐
Describe all answers marked “No” or “Fail” and proposed remedy in Section 9.
List all monitoring equipment either replaced or repaired in Section 9
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.)
X 3 GPH ☐ 0.1 GPH ☐ 0.2 GPH Yes No NA
Has the testing apparatus been properly calibrated? X ☐ ☐
For emergency generator tank systems, does the LLD create an audible and visual alarm
when a leak is detected? ☐ ☐ X
For mechanical LLDs, does the LLD restrict the flow through the pipe when a release is
detected? ☐ ☐ X
For electronic LLDs, does the turbine automatically shut off when a release is detected? X ☐ ☐
For electronic LLDs, does the turbine automatically shut off if any portion of the monitoring
system is disabled or disconnected? X ☐ ☐
For electronic LLDs, does the turbine automatically shut off if any portion of the monitoring
system malfunctions or fails a tightness test? X ☐ ☐
For electronic LLDs, have all accessible wiring connections been visually inspected for
kinks and breaks? X ☐ ☐
Were all items on the equipment manufacturer’s maintenance checklist completed? X ☐ ☐
Were all LLDs confirmed operational within regulatory requirements? X ☐ ☐
LLD ID LLD Model Lines Monitored Pass Fail
1 PLLD 87 X ☐
2 PLLD 91 X ☐
☐ ☐
☐ ☐
☐ ☐
☐ ☐
☐ ☐
☐ ☐
☐ ☐
☐ ☐
☐ ☐
☐ ☐
Describe all answers marked “No” or “Fail” and proposed remedy in Section 9.
List all monitoring equipment either replaced or repaired in Section 9
8. IN-TANK GAUGING TESTING
X 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.
Advanced Compliance
4007 Brae Burn Drive
Bakersfield, Ca. 93306
661-706-4321 Fax# 661-589-9329
VAPORLESS MANUFACTURING, INC.
LDT-890 Leak Detector Test Record
Contractor: Advanced Compliance Customer: ARCO White Ln.
Date: 7/6/2023 Location: 6450 White Ln. Bakersfield, Ca.
93309
Product: 87 Technician: Bruce W. Hinsley
Submersible Pump Identification
Manufacturer: Redjacket Model No.:
Serial No.: Notes:
Leak Detector Identification
Manufacturer: Veeder-Root Description: PLLD
Diaphragm-type: Piston-type:
Tamper-proof seal installed: Other Style Leak Detector:
Notes:
Leak Detector in Submersible Pump Test at Dispenser
Operating Pump Pressure (psi): 32 (para. 15)
Gallons per hour rate: 3.0 (para. 22)
Line pressure with pump shut off (psi): 19 (para. 23)
Bleed-back Test with pump off (ml): 10 (para. 26)
Step-through time to full flow (secs): N/A (para. 30)
Leak detector stays in leak search position (Yes/No): N/A (para. 42)
Leak Detector Test
Pass / Fail Notes:
Pass
*Complete thermal expansion test before failing leak detector
Advanced Compliance
4007 Brae Burn Drive
Bakersfield, Ca. 93306
661-706-4321 Fax# 661-589-9329
VAPORLESS MANUFACTURING, INC.
LDT-890 Leak Detector Test Record
Contractor: Advanced Compliance Customer: ARCO White Ln.
Date: 7/6/2023 Location: 6450 White Ln. Bakersfield, Ca.
93309
Product: 91 Technician: Bruce W. Hinsley
Submersible Pump Identification
Manufacturer: Redjacket Model No.:
Serial No.: Notes:
Leak Detector Identification
Manufacturer: Veeder-Root Description: PLLD
Diaphragm-type: Piston-type:
Tamper-proof seal installed: Other Style Leak Detector:
Notes:
Leak Detector in Submersible Pump Test at Dispenser
Operating Pump Pressure (psi): 28 (para. 15)
Gallons per hour rate: 3.0 (para. 22)
Line pressure with pump shut off (psi): 19 (para. 23)
Bleed-back Test with pump off (ml): 115 (para. 26)
Step-through time to full flow (secs): N/A (para. 30)
Leak detector stays in leak search position (Yes/No): N/A (para. 42)
Leak Detector Test
Pass / Fail Notes:
Pass
*Complete thermal expansion test before failing leak detector
Ver. 1.5 – 08.20.14
Shear Valve Operation Test
CERS ID: 10023058 Test Company: Advanced Compliance
Site Name: ARCO White Ln. Technician: Bruce W. Hinsley
Site Address: 6450 White Ln. Certification Number Expiration Date
City: Bakersfield Zip: 93309 ICC (SERVICE TECH): 8032698 6/23/2025
Date/Time of Test: 7/6/2023 08:30
Product
Grade
Dispenser
Number
1.Shear Valve
Type
(Product or
Vapor)
2. Is the
shear valve
properly
anchored?
3. Is the shear valve
within ½ in of dispenser
island?
4. Is the lever arm
free moving?
5. Does the lever
arm close poppet
valve?
6. Can you Dispense
with shear valve in
closed position?
Pass / Fail
87 1-2 P Y Y Y Y No Pass
91 1-2 P Y Y Y Y No Pass
87 3-4 P Y Y
91 3-4 P Y Y
87 5-6 P Y Y Y Y No Pass
91 5-6 P Y Y Y Y No Pass
87 7-8 P Y Y Y Y No Pass
91 7-8 P Y Y Y Y No Pass
87 9-10 P Y Y Y Y No Pass
91 9-10 P Y Y Y Y No Pass
87 11-12 P Y Y Y Y NO Pass
91 11-12 P Y Y Y Y NO Pass
.
Signature of Technician: ___________________________ Date: 7/20/2023
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 X 12 Month
1. FACILITY INFORMATION
CERS ID
10023058
Test Date
7/6/2023
Facility Name
ARCO White Ln.
Facility Address
6450 White Ln.
City
Bakersfield
ZIP Code
93309
2. SERVICE TECHNICIAN INFORMATION
Company Performing the Test
Advanced Compliance
Phone
661-706-4321
Mailing Address
4007 Brae Burn Dr Bakersfield Ca. 93306
Service Technician Performing Test
Bruce W. Hinsley
Contractor/Tank Tester License Number
971259
ICC Number
8032698
ICC Expiration Date
6/23/2025
3. TRAINING AND CERTIFICATIONS
Manufacturer and Test Equipment Training Certifications Expiration Date
ICC Service Techican 6/23/2025
4. TEST PROCEDURE INFORMATION
Test Procedures Used Components Tested
Industry Standard Spill Buckets
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
7/6/2023
Total # of Pages
6. SPILL CONTAINER DETAILS
Test Method Developed by ☐ Manufacturer X Industry Standard ☐ Professional Engineer
Underground Storage Tank
Spill Container Testing Report Form
Additional copies of this page may be attached.
Page 2 of 2
Test Type ☐ Pressure ☐ Vacuum X Hydrostatic
Tank ID 87 Main 87 Aux 91
Spill Container Manufacturer: OPW OPW OPW
Method of Cathodic Protection ☐ Nonmetallic
X Other
☐ Nonmetallic
X Other
☐ Nonmetallic
X Other
☐ Nonmetallic
☐ Other
Is the spill container minimum
capacity five gallons excluding riser
volume?
X Yes
☐ No*
X Yes
☐ No*
X Yes
☐ No*
☐ Yes
☐ No*
Method to keep spill container
empty
X Drain
☐ Pump
☐ Other
X Drain
☐ Pump
☐ Other
X Drain
☐ Pump
☐ Other
☐ Drain
☐ Pump
☐ Other
Spill Container Test Results X Pass
☐ Fail
X Pass
☐ Fail
X 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.
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