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Home My WebLink AboutEMC 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 10155971 10/19/23 Jaco #7773 Fastrip #31 3501 Mount Vernon Ave Bakersfield 93306 Nwestco LLC (800) 339-9930 2209 Zeus Court, Bakersfield, CA 93308 Mark Fisher 1073967 10278702 03/10/25 Veeder Root- C33847 07/24/25 10/19/23 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 TLS350 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 420 UNLEADED ANNULAR L2 420 DIESEL ANNULAR L4 208 UNLEADED STP L5 208 DIESEL STP L6 208 PREMIUM STP L7 420 PREMIUM ANNULAR L9 208 DISPENSER 1/2 L10 208 DISPENSER 3/4 L11 208 DISPENSER 5/6 L12 208 DISPENSER 7/8 L13 208 TRANSITION SUMP 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. ܆܆ Leak Detectors were not tested as they are not required on an electronic monitor certiﬁcation. 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. 10/19/23 PARKIN G 175'EXISTING BUILDINGNO PRICE SIGNMOUNT VERNON AVE.UNIVERSITY AVE.CATCHBASIN N 94.2'50'117.5'180'HSTPL4 AL1 V F L11 G W PROPERTY LINE PROPERTY LINEL12 L9L10 DUMPS T ER L13 12,000 GALLONDIESEL 12,000 GALLONPREMIUM40' STORAGE C ONTAINE R 40' STORAGE C ONTAINE R STPL5 AL2 V F STPL6 AL3 V F 12,000 GALLON87 UNL LEGEND L1 87 ANNULAR L2 DSL ANNULAR L3 91 ANNULAR L4 87 STP L5 DSL STP L6 91 STP L9 UDC 1 - 2 L10 UDC 3 - 4 L11 UDC 5 - 6 L12 UDC 7 - 8 L13 TRANS SUMP 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 2 INCH SINGLE 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 SITE MAP SITE PLAN C1 TAB:SITE PLAN 1"=10'-0" INCHES012 SHEET SIZE 22 X 34 DATE REVISIONS DATE: DRAWN BY: CHECKED: APPROVED: RAC FASTRIP - 7-773 CADFILE: SHEET NO.7773-MSP A.P.N.:382-020-16-00-8 SCALE: FASTRIP FOOD STORECONVENIENCE MARKET FOR: BAKERSFIELD, CALIFORNIA 93306 JAMIESON HILL 3501 MT VERNON AVE. 3101 STATE RDBAKERSFIELD, CA 93308 PROJECT OWNER: DRAWING: CD 10/13/2020 3501 MT VERNON AVE.BAKERSFIELD, CA 93306 MT VERNON AVE.UNIVERSITY AVE. PROJECT OWNER: JAMIESON HILL PO. BOX 82515 BAKERSFIELD, CA 93380 CONTACT: SITE PLOT PLAN FOR: FACILITY ID 15-021-003018 CERS ID 10155971 FASTRIP #7773 3501 MT VERNON AVE. BAKERSFIELD, CA 93306 10/13/2020 REV. VICINITY MAP PROJECT DATA