The URL can be used to link to this page

Home My WebLink AboutFMC 2024Appendix 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 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 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 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. FIEETA LIAU+H TI:I2J EAHEH ST F,t 1 -':JIil*4584 t'lrrR 5, l0!4 4:llri t't'1 F,JYETEI'] fiTATIJS EEPORT HLL FIJNI-:TIfl.I'IE I!|IEI'IAL ALHEI"I HIf;TiTEY EEP'IRT E'If;TEt'I ALf,RI.] FAPEE 4]UT FEE lT, ?1124 4: 1b F',|',',l F'F I I'ITEH EERIR FEB !7, l[24 4: 16 pl',l T 1:91 I:IETlJF llilTrt IilAFI'l ING(trrT !. ltlzl 1 1 :4'J Pl"1 'ti(:T l. tll!;l 1 1 :4::l PI.l ilr-rT 2, XLI?3 11 :il9 r'|',l HIGH I,iATEE *LAHI-I l:iEt, G[, !Ll!11 I:19 FI'l ,!EP It, t!23 1 :45 F't']riEF 5. I[li] Jl17 Ar'1 LL][,,I PEOTILICT ALARI'IEEp i, 2LrI3 t : 41 t',t'l SUDDEI'I LOSE ALAET'I N,]V Xt:r, !fl?x T : 55 *l,1 NOV 3[. ZOTS 7 : 3E AI"I ilr::T t, I[I3 g : Zt fll,l HIGH PF]}I)UCT HLAEI'I riEF, rr[, :r:l?s 2:19 Fl1 HEF' :i , IOIT 4 : I1 PF] FjEF, 3, 2u2tl X:44 F't-1 I N,JAL I D FUEL LEUEL trEr-r 15, 20lil I ll : ?! At'l t"l0u lh, 'JLl23 11 :38 Ar'l BEF, t, TLIIS 3:41 PI"] P.EOEE *UT+cT l. !,113 11:{.I Pl'l EEP iltr, l[Ii] I : ?E pl'1 EEF,tlll, 'JU23 1l:1! F'1"1 H l GH TJATEH IdAEI'lI I'lrj 5EP :ltl, rllf t I: 1t t'l'1 EEF, It, IOZS 1 :45 F'I,l ErEt, 5, ztllx t:17 flt'l t,rEL I UERY NEEITEII T EC 4, EI]ZT E : U5 PI'1t!ilu 15, ?u23 1 I : [,1 F',l'l f'l0\./ 1:r., llllS 10:5? nt''] I.1A}i PRf,\[TUI]T ALAEI'I EEF, |JIJ, IIXE 2 : ?4 PIlBEF T, IDIS 4:11 PI"]EEP I+. 2tl?il il:44 Pt'l I]ELD I I,II]F] EATE t,iAHI'I I'l{lV 13, 2013 fi: LlLr i1t'1 t'10v 11. 2E2ij t:57 f,l'1 L+L,J TEI'IF' TJARNI NL;ilcT l, lrllx 1t:44 FI'l ALAEI.I HISTOEY EEP+ET --. I N_TANK ALAEI1 1 J.DI HIGH L'J*TEE ALAFT'IocT 20, 2023 12:52 Pt{ BEP 3U, 2023 le r 44 PI'l OVEEF I LL ALARI,IOCT 17, EBES 6 : 4E FI,I LOH FRONUCT ALAEI'IsEP 5, 2U23 1[:54 AI"lsEP 1,2023 t:23f;tYsEp 1. 2[?3 t:82 At"l 5UDT]EI,] LOEE *LAEI,IFiEP 1 , lll2! 12:45 *t'1*uG 29, I0lil 2 : 44 *t'1 AUG lE, ltllx 2 : t:t AI'1 HITJH PR(J,DUIJT ALAHI'1Hurl xll. 2[13 I I : 56 At"] I NI/AL I TI FUEL LEVELiltrT 3, 2tll3 1 1 : E7 pf"l EEF, 5, 2tI!E l LI:54 AI,] PEOEE OUT oi::T zlt, t[23 1 2 : 4.1 E,l'l SEF' 3Ll. ?llllj 1 I :41 nl1 nEr Clr JUJ,J C.JE lll H I GH tnHTER t^lAEl'il NGorlT ?tr, ?rlZx 1 2 : 52 F,t'1EEt, 3[, ?r]E3 1 2 : 44 Pt'1 T]EL ] VEEY I"IEEDED.lAt'l lb, I0I4 ?:1r-, frPl T)EC IE, TI]T'J E: 1? PI']IrEri 4. 20tt 4 : 51 Pt,l l"lAi:,i PR{tDUtT ALAEI,I AUr-; 30, ?t123 1 E : Eb Al,l Ll:ti TEI'IP t{AEl'll I'lC; ur:;T 2[, l02t 1 2 : 5rr Pf,lot:T l, lD23 1 1 : 16 rrtlBEP 1, En23 1:?4 At'1 I 'S,r)a L{IIi F'R{JDUI:IT ALAFI.IIErl 1, ?l-t2t l:l? F,f,ll'l+u I7, t0?il 7:14 AtlsEF 3l], f[t3 4:t1 Pt'1 SLINTJEI,J LOEE ALiIFI.] I,IDV Gr:r , lll2ij 7 r 5E fit,t l,lO\J I[, ![!t 7 : XE *1.1 I t,,11/AL I tr FUEL LEVELfrEC 1 , l[EIr :]:46 F,l'll'l0tr' 1 T, l0lt E : tl6 At'1 EEF' trl, 20tx 5 : 2E Pt'1 PHOEE OUT SEP ?S, 2823 EEP 28, 2t123 xi4r+xEFltLx**rx rxxxxEl'itlt#xxx *xxrrEMxxxrx HLHBI'I HIBT(JEY HET,UFIT ALI]EI'I H]ETORY REPOET .--- II'I-TAI,]H *LAEI.1 -*_- II,I-TANH ALARI,I E : 31 Ft'lz: tl6 Pt"1 TJEL I \.IEF]Y I,,IEEITETI DEr:: 13, ZIIX 1?;?1 Pl'l nE{:: 18, 2lll3 1 1 :34 ltlt"l TIEC ?, TCII3 E : 3[ PI"l CF-rLD I l,ltlE HATE tilAEN llil\,/ 11. 2ttl2 1l:5t flIl I,iO! I B, 2lll2 1 : ll,q AI'1 x;{sxxEMrxx*r* frL*EI.l H]ET|]ET' REPilET l:iEI,liluR ALAFTI'1L 1;F, II, INIJ f;UI"lF'PIFIN$ FUI'1T' I-.JEI',Ig+TL +UT ALf,RI'l FEE 13. lr-]24 t:41 Al',l FIJEL *LAEI'I FEE 1 i, e[I4 I : 17 Al',] EENSI-IR (JUT f,LAEI"lJAl,l :j, 2LtI[ 1 I : 4t Pl'] xxtil*EllD**fx* ALAEI'I H I ET0E''I' EEF (lHT EENST\H *L*EI'1 {ITHEE SENEOHE TL*RI,I HISTOEY EEPORT EENEOF ALARI,IT q. OTHEE SENSORS ilHisXxEI'l[] XXri(* AL*RI'1 HISTOEY REPCIHT --- DISPENSER ALAR]"I ----E 1: COI'II,IUN I CAT I +N ALftEI.l AUG 25, 2023 10:50 Atl COI4I,IUFIICAT I ON ALAE. ] APR 17 , ?A23 3: U6 At{ C+MI,IUN I CAT I SN f,LAEI.1DEC ?, 2022 9 :47 At.l *rx*xEt"lIl xH#xr; II1LARI'1 HIFJTDEY REF'ORT F,RODU[:T *LA]it,.l -*-*F 1:91 flL*RI.1 HIETORY REPOET SENSOR ALARI,I tAJ 1:91 LJF'LLD SHUTDOIIJI{ ALtlt'lflR 5, 2024 E : U7 Fr"l GROSS LINE FAILt'1AR 5. 2124 3:07 Pt,l I^JPLLD SHUTDOTiJN ALr"'lFEE 1 3, ?rl?4 I : 41 At"l I^JPLLD SHUTDOI^IN ALt"lFEE I 3, 2A24 9:27 AI9 I^IPLLD EHUTD0[^jN ALt'lJAI,I 7 , -tgz4 1D:03 At"l PERIODIC LINE FAILDErj 30, EtlES 1 tl : 1 F, fll,l I'IPLLD SHUTDOI^JN ALI,IDEC 25, 2023 10:03 At'l FUEL OUTDEC 7, 2023 5:46 Ft"l T,ER]ODIC LINE FAILDEC 3, ZO23 1:DI AI,I I^IPLLD SHUTDOIIjN ALI'INOV 17, 20?3 l2:16 PH fiix.*xEtrlDxxrrx xi{xxxENDrxxxx xxxxxENDxxx*x AL*RI'I HIsr0RY FEP+Rr HILt?r:'BIE!',*rtLT *, EENSOH ALAEI'I til 2: 87I,ipiin EHUTDotiJN ALr'1 t'JpLLx EHUTDot'lN ALI"I fllE"irl''Eu-z+ rs:25 At"l Jnt! ?' s0?4 ID:rl:1 Ar-1 GEOEE LiNE FAiL I'JFLLD FHUTDOI,JN ALI'I iEE"I-rl'i-usi ig;2s rlH DEC ?b' 2023 10:rB AM r,lpLLD SHUTDOHN ALl.1 IiJFLLD EHUTDDLJN ALI.I FEE 1 E, z[?4 '] , i't *t'1 ocr E0 ' 2u2B I 0 : 03 At'l t^tpLLD EHUTDO6N ALI.1 t^lF'LLl EHUTIIOT^IN ALI'I FEE 18, E0z4 g,Ii *u of,T lE' 2rlr3 1[:tl3 At-1 t"lPLLD SHUTDilt^lN ALH FUEL OUT JAt,l ?, 21J24 tu:Ee *t"1 ocr ?' E[Er 5:40 Pt'l I^IPLLD SHUTDOT^1;"I *Lt'1 t'ipl-I.! EHUTITOI^IN ALt'l nEt 26, ED23 lU:nS *t'1 EEP i?' zSZE ILr:03 i1t'l FUEL OUTilic- t , 2023 z:28 PI.l FUEL OUTirov- s, ?r:r23 4:49 Pl"l t"iF'LLD SHUTDOIIIN ALI'Ifili"Io;'Iuzs.ro:us nH x x x x x END x x x x x t^lt'LLD SHUTDOT^IN ALt"l {icT-15, ztrzs t 2:22 t'l'l TILAHI'I HIETitE'i EEPIET * fjt,lfrFTfjENE,r-iR rll*El'1 -- = 1:Fl-il['l l'lETEE 1-? r{i4ri*xEI'iD*Hit-ri x}f,xxEl'lDx*xHx ftLfiHI"1 IIIET(}E!' HEPfiRT SENSOE ALAFII lij E: BB l,lPLLn SHUTD0I^JN ALt'l' r"lilR- 5, 2024 3:zo PI'l IJFOEIJ LII'IE FTlIL t,l*E E. IBZ4 E : 20 Pt1 ALART'I H I STOEY REPOE I r,rpLLD sHurno'rN AL, ;-;,Fif;fitfiE+EHRBftIAEH -- FLE- i r. 2fl24 s : 4l ftl'1 ri*X"iiEI,JI)iiI}i#x HLF]RI'1 HII:JT*EY EEF'OET -*- El'lfiRTilEl{E0R ALHRl,l *- : ,l: ALfiRl,l HIi:;T*Ftt' EEF,0HT :i r r x ic Er,rD x !i . x * ;-i;.lEi HoHELfiL*Et'l *--- FLOt,,l tlilI-LECT l,,l*81,1 t,tAFt 1 t, E0lt 1 ll I 0t Ht,l xxxxxElrltrHx*nx AL*EI'I HIIJTUR'/ FEF.ORT --*- IEIt H+FjE *LAFI,I --*-['r 1:FF, 1; ELEI'JIrE FLOI,] T,.]LLEf;T bIAEI"IIrEC 14, IulI{ i t_r: tl! At,l IiiXri*El,l.lltXtxfi ALHRI'] HlSTOE"/ EEF,{JI.T ---- IEIr HOiiE ALAEl"l -*--t-r E:FPiJ: ELEtlDll ALAEI1 HIST(JRI/ EEF'IIET -* IED HOSE HLARI'1 -..* IT 4:FF,4T ELEI'103 FL(JLI| I::fiLLEIIT FA]LJAl,l 7, 2tll4 1 tl : 0:r frl.1 FLOt,,l (-:(:)LLEtlT tIAHN.lAN E. Iu24 1rl:t[] 'tf'l FL.-II,./ I.:}LLECT Ff, IL I,E(_: ?E,, lt-l?3 1 0 : [3 *t,] xE*rrEtrltrtHx** f,LARI'l HIFJTOF]Y REF"iIRT -*-- ISIr FITE ALAFII'I **-- I5[r r;R(]I;lf F'FES I,JARl'iFEE 1?. 2rJt4 1 u: lil Al1IliD \,riiF'OFl LEAIi tJAEI'l.,'lf+H 1 , ll:|14 1t:t: l]3 *t'1 I F*][] \,,,'AP,''18 LEAH FA ] LDEri lE,. lrJ:s 1[r :Dt ,it,,] t"] I BH I tlrl Tnl"lli FiETUt, LtEt, 3Lt, !rl2! 1 I r il8 fit,lIET] FJETLIP I,IFFiNEEt, 19, 2[13 1 Ll : 0it At"]IEr[ EEI']EfiFl OUT t^iARr,lFjEF E, Iltii 1U:LlS til'lI5D SEt'lFiUE llLlT F4lLEEt, tlD. Ir-rI3 1 tl : tl3 Al,l *HH*xEl,lD#x xx *rxxxENllrxx*x Appendix VIIIUnderground 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 12 Month 1. FACILITY INFORMATION CERS ID Test Date Facility Name Facility Address City ZIP Code 2. SERVICE TECHNICIAN INFORMATION Company Performing the Test 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.TEST PROCEDURE INFORMATION Test Procedures Used Components Tested 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 Total # of Pages ✔ 2/13/24 FIESTA LIQUOR 2023 BAKER BAKERSFIELD BSSR, INC 661-588-2777 6630 ROSEDALE HWY NATHAN HOLMAN 672812 8111067 8/23/24 OPW 10/20/24 1 HR HYDROSTATIC 87,89,91 FILL BUCKETS AND 91 VAPOR BUCKET 2/13/24 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 Industry Standard Professional Engineer Test Type Pressure Vacuum Hydrostatic 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 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. ✔ ✔ 87 89 91 91 VAPOR ✔✔✔✔ ✔✔✔✔ ✔✔✔ ✔✔✔✔ PEI/RP1200-12 pei.org50 APPENDIX C-10 SHEAR VALVE OPERATION INSPECTION )DFLOLW\1DPH2ZQHU$GGUHVV$GGUHVV&LW\6WDWH=LS&RGH&LW\6WDWH=LS&RGH)DFLOLW\,'3KRQH7HVWLQJ&RPSDQ\3KRQH7KLVGDWDVKHHWLVIRULQVSHFWLQJVKHDUYDOYHVORFDWHGLQVLGHGLVSHQVHUV6HH3(,536HFWLRQIRUWKHLQVSHFWLRQSURFHGXUH3URGXFW*UDGH'LVSHQVHU,' 6KHDU9DOYH7\SH3URGXFW9DSRU,VWKHVKHDUYDOYHULJLGO\DQFKRUHGWRWKHGLVSHQVHUER[IUDPHRUGLVSHQVHULVODQG"<HV1R<HV1R<HV1R<HV1R<HV1R<HV1R<HV1R<HV1R<HV1R,VWKHVKHDUVHFWLRQSRVLWLRQHGEHWZHHQóLQFKDERYHRUEHORZWKHWRSVXUIDFHRIWKHGLVSHQVHULVODQG"<HV1R<HV1R<HV1R<HV1R<HV1R<HV1R<HV1R<HV1R<HV1R,VWKHOHYHUDUPIUHHWRPRYH"<HV1R1$<HV1R1$<HV1R1$<HV1R1$<HV1R1$<HV1R1$<HV1R1$<HV1R1$<HV1R1$'RHVWKHOHYHUDUPVQDSVKXWWKHSRSSHWYDOYH"<HV1R1$<HV1R1$<HV1R1$<HV1R1$<HV1R1$<HV1R1$<HV1R1$<HV1R1$<HV1R1$&DQDQ\SURGXFWEHGLVSHQVHGZKHQWKHSURGXFWVKHDUYDOYHLVFORVHG"<HV1R1$<HV1R1$<HV1R1$<HV1R1$<HV1R1$<HV1R1$<HV1R1$<HV1R1$<HV1R1$$´1RµWR/LQHVRUD´<HVµIRU/LQHLQGLFDWHVDWHVWIDLOXUHTest Results3DVV)DLO3DVV)DLO3DVV)DLO3DVV)DLO3DVV)DLO3DVV)DLO3DVV)DLO3DVV)DLO3DVV)DLOComments:7HVWHU·V1HPH BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB 7HVWHU·V6LJQDWXUH BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBFIESTA LIQUOR2023 BAKERBAKERSFIELD,CABSSR INC8789918789911-21-21-23-43-43-4PRODUCTPRODUCTPRODUCTPRODUCTPRODUCTPRODUCTNATHAN HOLMAN