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Home My WebLink AboutFMC 2023CERS = 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 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 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 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 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. SHEAR VALVE OPERATION INSPECTION Facility Name: Owner Address: Address City, State, Zip Code: City, State, Zip Code: Montana 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 7/8/2021 < I10100 OCT 18, 2023 1:39 PM CIRCLE K 2701270 5634 STINE RD. BAKERSFIELD, CA 80749873405001 SYSTEM STATUS REPORT h 3:DEGRD COLLECT WARN > < I20100 OCT 18, 2023 1:39 PM CIRCLE K 2701270 5634 STINE RD. BAKERSFIELD, CA 80749873405001 IN-TANK INVENTORY TANK PRODUCT VOLUME TC VOLUME ULLAGE HEIGHT WATER TEMP 1 UNL-REG(005) 8831 8714 5594 69.31 0.00 78.84 2 UNL Premium 3617 3559 8232 40.94 0.00 82.96 > < I51700 OCT 18, 2023 1:39 PM SYSTEM TYPE AND LANGUAGE FLAG SYSTEM UNITS U.S. SYSTEM LANGUAGE ENGLISH SYSTEM DATE/TIME FORMAT MON DD YYYY HH:MM:SS xM > < I50F00 OCT 18, 2023 1:39 PM MON DD YYYY HH:MM:SS xM 1 > < I60100 OCT 18, 2023 1:39 PM TANK CONFIGURATION DEVICE LABEL CONFIGURED 1 UNL-REG(005) ON 2 UNL Premium ON 3 OFF 4 OFF > < I60200 OCT 18, 2023 1:39 PM TANK PRODUCT LABEL TANK PRODUCT LABEL 1 UNL-REG(005) 2 UNL Premium 3 4 > < I60300 OCT 18, 2023 1:39 PM TANK PRODUCT CODE TANK PRODUCT LABEL 1 UNL-REG(005) A 2 UNL Premium B 3 3 4 4 > < I60400 OCT 18, 2023 1:39 PM TANK FULL VOLUME TANK PRODUCT LABEL GALLONS 1 UNL-REG(005) 14425 2 UNL Premium 11849 3 0 4 0 > < 2 I60700 OCT 18, 2023 1:39 PM TANK DIAMETER TANK PRODUCT LABEL INCHES 1 UNL-REG(005) 117.75 2 UNL Premium 117.75 3 0.00 4 0.00 > < I60900 OCT 18, 2023 1:39 PM TANK THERMAL COEFFICIENT TANK PRODUCT LABEL 1 UNL-REG(005) 0.000700 2 UNL Premium 0.000700 3 0.000000 4 0.000000 > < I61200 OCT 18, 2023 1:39 PM TANK MANIFOLDED PARTNERS TANK PRODUCT LABEL SIPHON MANIFOLDED TANKS LINE MANIFOLDED TANKS 1 UNL-REG(005) NONE NONE 2 UNL Premium NONE NONE 3 NONE NONE 4 NONE NONE > < I62100 OCT 18, 2023 1:39 PM TANK LOW PRODUCT LIMIT TANK PRODUCT LABEL GALLONS 1 UNL-REG(005) 1084 2 UNL Premium 900 3 0 4 0 > < I62200 OCT 18, 2023 1:39 PM 3 TANK HIGH PRODUCT LIMIT TANK PRODUCT LABEL GALLONS 1 UNL-REG(005) 13704 2 UNL Premium 11257 3 0 4 0 > < I62300 OCT 18, 2023 1:40 PM TANK OVERFILL LEVEL LIMIT TANK PRODUCT LABEL GALLONS 1 UNL-REG(005) 12983 2 UNL Premium 10664 3 0 4 0 > < I62400 OCT 18, 2023 1:40 PM TANK HIGH WATER LEVEL LIMIT TANK PRODUCT LABEL INCHES 1 UNL-REG(005) 2.5 2 UNL Premium 2.5 > < I62800 OCT 18, 2023 1:40 PM TANK MAXIMUM VOLUME LIMIT TANK PRODUCT LABEL GALLONS 1 UNL-REG(005) 14425 2 UNL Premium 11849 3 0 4 0 > < I62900 OCT 18, 2023 1:40 PM TANK DELIVERY REQUIRED LIMIT TANK PRODUCT LABEL GALLONS 1 UNL-REG(005) 1443 2 UNL Premium 948 3 0 4 4 0 > < I70300 OCT 18, 2023 1:40 PM LIQUID TYPE SENSOR LOCATION TYPE 1 87 ANNULAR TRI-STATE (SINGLE FLOAT) 2 87 TURBINE TRI-STATE (SINGLE FLOAT) 3 91 ANNULAR TRI-STATE (SINGLE FLOAT) 4 91 TURBINE TRI-STATE (SINGLE FLOAT) 5 UDC 1-2 TRI-STATE (SINGLE FLOAT) 6 UDC 3-4 TRI-STATE (SINGLE FLOAT) 7 UDC 5-6 TRI-STATE (SINGLE FLOAT) 8 UDC 7-8 TRI-STATE (SINGLE FLOAT) > < I20600 OCT 18, 2023 1:40 PM CIRCLE K 2701270 5634 STINE RD. BAKERSFIELD, CA 80749873405001 TANK ALARM HISTORY TANK 1 UNL-REG(005) LOW PRODUCT ALARM OCT 10, 2023 1:24 AM JUL 12, 2023 8:12 AM APR 29, 2023 4:55 PM DELIVERY NEEDED OCT 9, 2023 7:17 PM SEP 15, 2023 9:29 AM JUL 11, 2023 11:38 PM TANK 2 UNL Premium TANK 5 TANK 6 TANK 7 TANK 8 TANK 9 5 TANK 10 TANK 11 TANK 12 TANK 13 TANK 14 TANK 15 TANK 16 > < I30200 OCT 18, 2023 1:41 PM CIRCLE K 2701270 5634 STINE RD. BAKERSFIELD, CA 80749873405001 LIQUID ALARM HISTORY REPORT SENSOR LOCATION 1 87 ANNULAR OCT 18, 2023 12:30 PM FUEL ALARM OCT 18, 2023 12:30 PM FUEL ALARM OCT 18, 2023 11:04 AM FUEL ALARM 2 87 TURBINE OCT 18, 2023 11:03 AM SENSOR OUT ALARM OCT 18, 2023 10:59 AM FUEL ALARM AUG 8, 2023 9:20 AM SETUP DATA WARNING 4 91 TURBINE OCT 18, 2023 11:03 AM SENSOR OUT ALARM OCT 18, 2023 10:58 AM FUEL ALARM AUG 8, 2023 9:20 AM SETUP DATA WARNING 5 UDC 1-2 OCT 18, 2023 11:03 AM SENSOR OUT ALARM OCT 18, 2023 10:59 AM FUEL ALARM AUG 10, 2023 8:58 AM FUEL ALARM 6 UDC 3-4 OCT 18, 2023 11:03 AM SENSOR OUT ALARM OCT 18, 2023 11:00 AM FUEL ALARM AUG 10, 2023 9:01 AM FUEL ALARM 7 UDC 5-6 OCT 18, 2023 11:03 AM SENSOR OUT ALARM OCT 18, 2023 11:01 AM FUEL ALARM 6 AUG 10, 2023 9:00 AM FUEL ALARM 8 UDC 7-8 OCT 18, 2023 11:03 AM SENSOR OUT ALARM OCT 18, 2023 11:00 AM FUEL ALARM AUG 10, 2023 9:00 AM FUEL ALARM > < I10100 OCT 18, 2023 1:41 PM CIRCLE K 2701270 5634 STINE RD. BAKERSFIELD, CA 80749873405001 SYSTEM STATUS REPORT h 3:DEGRD COLLECT WARN > < I90200 OCT 18, 2023 1:41 PM SOFTWARE REVISION LEVEL VERSION 336.02 SOFTWARE# 346336-100-C CREATED - 21.02.13.11.53 S-MODULE# 330160-004-a SYSTEM FEATURES: PERIODIC IN-TANK TESTS ANNUAL IN-TANK TESTS ISD/APM > 7