HomeMy WebLinkAboutEMC 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
9/19/2023
Fastrip
4013 So. H St. Bakersfield CA.93304
Nwestco LLC (800) 339-9930
2209 Zeus Court, Bakersfield, CA 93308
Matt Story
1073967
9118985 2/3/2025
GVR ATG Tech C26845 4/21/2025
9/19/2023 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 350 336.02
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 87 STP Sump
L2 794380-420 87 Tank Annular
L3 794380-208 91 STP Sump
L4 794380-420 91 Tank Annular
L5 794380-208 Diesel STP Sump
L6 794380-420 Diesel Tank Annular
L9 794380-208 UDC 9-10
L10 794380-208 UDC 11-12
L11 794380-208 UDC 13-14
L12 794380-208 UDC 15-16
L13 794380-208 UDC 17-18
L14 794380-208 UDC 19-20
Underground Storage Tank
Monitoring System Certification Form
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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.
܆܆
Perfoemd EMC due to cold start.
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.
F
EXISTING BUILDING
NOPARKING
56L11
#7-781
78L10 34L12
12L9
12,000 GALLON87-1 UNLEADED
12,000 GALLON87-2 UNLEADED
12,000 GALLONPREMIUM
12,000 GALLONDIESEL
V AL2 STPL1
FV AL6 STPL5
FV AL8 STPL7
F AL4 STPL3 109L91413L121211L101615L122019L141817L1312,000 GALLON87 UNLEADED12,000 GALLONPREMIUM12,000 GALLONDIESELFAL6STPL5FVAL4STPL3FVAL2STPL1NOPARKING
G
W
7-721
7-781
#7-721DUMPSTER H
H
PRICE SIGN
PRICE SIGN
40' STORAGE CONTA
INER
S. H ST.WHITE LN.PROPERTY LINE
PROPERTY LINE
N
CAT
C
HBAS
I
N
721 LEGEND
L1 87 STP
L2 87 ANNULAR
L3 91 STP
L4 91 ANNULAR
L5 DSL STP
L6 DSL ANNULAR
L9 UDC 9 - 10
L10 UDC 11 -12
L11 UDC 13 - 14
L12 UDC 15 - 16
L13 UDC 17 - 18
L14 UDC 19 - 20
781 LEGEND
L1 87-1 STP
L2 87-1 ANNULAR
L3 DSL STP
L4 DSL ANNULAR
L5 87-2 STP
L6 87-2 ANNULAR
L7 91 STP
L8 91 ANNULAR
L9 UDC 1 -2
L10 UDC 7 - 8
L11 UDC 5 -6
L12 UDC 3 - 4
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 3/2 INCH DOUBLE WALLED PIPE
PRODUCT SPILL CONTAINER
VAPOR SPILL CONTAINER
ANNULAR
EMERGENCY SHUT-OFF
OVERFILL ALARM
FIRE EXTINGUISHER
GAS METER SHUT-OFF
WATER METER SHUT-SHUT OFF
HEALY CAS
EVACUATION MEETING POINT
CIRCUIT BREAKER
UST ELECTRICAL PANEL
AUTOMATIC TANK GAUGE
AIR AND WATER DISPENSER
HAZWASTE DRUM
W
G
A
H
P
V
SCALE:
SITE MAP
C1
VICINITY MAP
PROJECT DATA
3/32"=1'-0"
INCHES012
SHEET SIZE 22 X 34
4013 S. H ST.
BAKERSFIELD, CA 93304
PROJECT OWNER:
JAMIESON HILL
PO. BOX 82515
BAKERSFIELD, CA 93380
CONTACT:
SITE PLOT PLAN FOR:
FASTRIP #7721
FACILITY ID 15-021-100296
CERS ID 10159161
FASTRIP #7781
FACILITY ID 15-021-003022
CERS ID 10159163
4013 S. H ST.
BAKERSFIELD, CA 93304
03/02/17 REV.S. H ST.WHITE LN.