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Home My WebLink AboutFMC 2023 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 5 TYPE OF ACTION ☐ Installation ☐ Repair ☒ 12 Month 1. FACILITY INFORMATION CERS ID 10156151 Certification Date 12/13/2023 Facility Name Sullivan's Chevron Coffee Facility Address 6009 Coffee Rd. City Bakersfield ZIP Code 93308 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 6/26/2023 3. TRAINING AND CERTIFICATIONS Manufacturer and Test Equipment Training Certifications Expiration Date Veeder-root 3/19/2024 Redjacket LLD 12/9/2025 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 12/13/2023 Total # of Pages 5 Underground Storage Tank Monitoring System Certification Form Page 2 of 5 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 336.01 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 Underground Storage Tank Monitoring System Certification Form Page 3 of 5 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 794380-208 87 STP X ☐ L-2 794380-304 87 STP Annular X ☐ L-3 794380-208 87 Fill X ☐ L-4 794380-304 87 Fill Annular X ☐ L-5 794380-303 87 Tank Annular X ☐ L-6 794380-208 91 STP X ☐ L-7 794380-304 91 STP Annular X ☐ L-8 794380-208 91 Fill X ☐ L-9 794380-304 91 Fill Annular X ☐ L-10 794380-303 91 Tank Annular X ☐ L-11 794380-208 Diesel STP X ☐ L-12 794380-304 Diesel STP Annular X ☐ L-13 794380-208 Diesel Fill X ☐ L-14 794380-304 Diesel Annular X ☐ L-15 794380-303 Diesel Tank Annular X ☐ L-16 794380-208 Vent Pan X ☐ L-17 794380-304 Vent Pan Annular X ☐ L-18 794380-208 Dispenser 1-2 X ☐ L-19 794380-304 Dispenser 1-2 Annular X ☐ L-20 794380-208 Dispenser 3-4 X ☐ L-21 794380-304 Dispenser 3-4 Annular X ☐ L-22 794380-208 Dispenser 5-6 X ☐ L-23 794380-304 Dispenser 5-6 Annular X ☐ L-24 794380-208 Dispenser 7-8 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 Underground Storage Tank Monitoring System Certification Form Page 4 of 5 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-25 794380-304 Dispenser 7-8 Annular X ☐ L-26 794380-208 Dispenser 9-10 X ☐ L-27 794380-304 Dispenser 9-10 Annular X ☐ L-28 794380-208 Dispenser 11-12 X ☐ L-29 794380-304 Dispenser 11-12 Annular X ☐ S-1 330020-485 87 Product Line X ☐ S-2 330020-485 Vent Line X ☐ S-3 330020-485 87 Vent Line X ☐ S-4 330020-485 91 Vent Line X ☐ S-5 330020-485 91 Prlduct Line X ☐ S-6 330020-485 Diesel Vent Line X ☐ S-7 330020-485 Diesel Product Line 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 Underground Storage Tank Monitoring System Certification Form Page 5 of 5 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 87 FX-1V 87 X ☐ 91 FX-1V 91 X ☐ Diesel FX-1DV Diesel 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 Underground Storage Tank Monitoring System Certification Form Page 6 of 5 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 VAPORLESS MANUFACTURING, INC. LDT-890 Leak Detector Test Record Contractor: Advanced Compliance Customer: Sullivan's Chevron Coffee Date: 12/13/2023 Location: 6009 Coffee Rd. Bakersfield, Ca. 93308 Product: 87 UL Technician: Bruce W. Hinsley Submersible Pump Identification Manufacturer: Redjacket Model No.: Serial No.: Notes: Leak Detector Identification Manufacturer: Redjacket Description: FX-1V 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): 26 (para. 15) Gallons per hour rate: 3.0 (para. 22) Line pressure with pump shut off (psi):26 (para. 23) Bleed-back Test with pump off (ml): 185 (para. 26) Step-through time to full flow (secs): 3 (para. 30) Leak detector stays in leak search position (Yes/No): Yes (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 VAPORLESS MANUFACTURING, INC. LDT-890 Leak Detector Test Record Contractor: Advanced Compliance Customer: Sullivan's Chevron Coffee Date: 12/13/2023 Location: 6009 Coffee Rd. Bakersfield, Ca. 93308 Product: 91 UL Technician: Bruce W. Hinsley Submersible Pump Identification Manufacturer: Redjacket Model No.: Serial No.: Notes: Leak Detector Identification Manufacturer: Redjacket Description: FX-1V 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): 27 (para. 15) Gallons per hour rate: 3.0 (para. 22) Line pressure with pump shut off (psi):18 (para. 23) Bleed-back Test with pump off (ml): 190 (para. 26) Step-through time to full flow (secs): 3 (para. 30) Leak detector stays in leak search position (Yes/No): Yes (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 VAPORLESS MANUFACTURING, INC. LDT-890 Leak Detector Test Record Contractor: Advanced Compliance Customer: Sullivan's Chevron Coffee Date: 12/13/2023 Location: 6009 Coffee Rd. Bakersfield, Ca. 93308 Product: Diesel Technician: Bruce W. Hinsley Submersible Pump Identification Manufacturer: Redjacket Model No.: Serial No.: Notes: Leak Detector Identification Manufacturer: Redjacket Description: FX-1DV 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): 33 (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): 110 (para. 26) Step-through time to full flow (secs): 3 (para. 30) Leak detector stays in leak search position (Yes/No): Yes (para. 42) Leak Detector Test Pass / Fail Notes: Pass *Complete thermal expansion test before failing leak detector 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 10156151 Test Date 12/13/2023 Facility Name Sullivan's Chevron Coffee Facility Address 6009 Coffee Rd. City Bakersfield ZIP Code 93308 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 6/26/2025 3. TRAINING AND CERTIFICATIONS Manufacturer and Test Equipment Training Certifications Expiration Date 4. TEST PROCEDURE INFORMATION Test Procedures Used Components Tested Industry Standard 87, 91 & Diesel 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 12/13/2023 Total # of Pages 2 Underground Storage Tank Spill Container Testing Report Form Additional copies of this page may be attached. Page 2 of 2 6. SPILL CONTAINER DETAILS Test Method Developed by ☐ Manufacturer X Industry Standard ☐ Professional Engineer Test Type ☐ Pressure ☐ Vacuum X Hydrostatic Tank ID 1 2 3 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. Ver. 1.5 – 08.20.14 Shear Valve Operation Test CERS ID: 10156151 Test Company: Advanced Compliance Site Name: Sullivan's Chevron Coffee Technician: Bruce W. Hinsley Site Address: 6009 Coffee Rd. Certification Number Expiration Date City: Bakersfield Zip: 93308 ICC (SERVICE TECH): 8032698 6/26/2025 Date/Time of Test: 12/13/2022 09:00 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 Product Yes Yes Yes Yes No Pass 91 1-2 Product Yes Yes Yes Yes No Pass 87 3-4 Product Yes Yes Yes Yes No Pass 91 3-4 Product Yes Yes Yes Yes No Pass 87 5-6 Product Yes Yes Yes Yes No Pass 91 5-6 Product Yes Yes Yes Yes No Pass 87 7-8 Product Yes Yes Yes Yes No Pass 91 7-8 Product Yes Yes Yes Yes No Pass 87 9-10 Product Yes Yes Yes Yes No Pass 91 9-10 Product Yes Yes Yes Yes No Pass Dsl 9-10 Product Yes Yes Yes Yes No Pass 87 11-12 Product Yes Yes Yes Yes No Pass 91 11-12 Product Yes Yes Yes Yes No Pass Dsl 11-12 Product Yes Yes Yes Yes No Pass . 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