HomeMy WebLinkAboutFMC 2023 REPAIR
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
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
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
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
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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 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
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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 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
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9. COMMENTS
Describe all answers marked “No” or “Fail” and proposed remedy.
List all monitoring equipment either replaced or repaired.
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.
1/10/24
CERTIFICATE:No.EXP:
International Code Council UST Installation/Retrofitting 8259798 9/06/2024
International Code Council California UST Service Tech 8259798 9/02/2024
International Code Council Vapor Recovery Installation/Repair 8259798 6/02/2024
Gilbarco Veeder-Root ATG Tech B34038 1/31/2024
Service Agent License 30454 2/11/2024
EMCO Wheaton Retail- Phase I EVR & Phase II EVR Systems 03524 7/06/2025
Bravo 2018-2929107 10/14/2025
Icon Installer Sump Repair Products Complete 2/01/2025
ZCL|Xerxes Underground Storage Tank 14812 6/13/2025
Containment Solutions Fiberglass Tank & DW Sump Installation Tech Complete 8/16/2021
OPW Phase 1 UST- Enhanced Vapor Recovery 148612 8/03/2025
OPW Phase 1 AST - Enhanced Vapor Recovery 148612 8/03/2025
OPW Flexworks System 148612 3/14/2025
Franklin Fueling- Stage II Vapor Recovery 1007843709 7/28/2025
Franklin Fueling- Sump Test System LVL 4 1007843709 7/25/2025
Franklin Fueling- Flexible Connectors 1007843709 7/28/2025
Franklin Fueling- FFS EVR Phase I System 1007843709 7/03/2025
Franklin Fueling- FMS Installation-Incon level 1 & level 2 1007843709 7/28/2025
Franklin Fueling- Monitoring Incon LVL 5 1007843709 7/28/2025
Franklin Fueling- Submersible Pimps 1007843709 3/21/2025
Vaporless- LLC Mechanical Line Leak Detectors 2445 7/05/2025
Vaporless- Mechanical Line Leak Detectors 2446 7/05/20205
Veeder-Root Vapor Products-US B34038 3/29/2024
Red Jacket Mech Line Leak Detector B34038 8/14/2025
API WorkSafe WS-585310d4 8/08/2024
Hose Master LLC Complete 10/14/2024
Universal Valve- 47-20 waste oil Tank Overfill 91423-2 9/14/2025
Modern Welding Complete 8/15/2025
CNI-Manufacturing No. 5110 11/06/2025
NOV UL Bonder (Pipe)Complete 5/18/2026
RUBEN AUDELO CERTIFICATIONS