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HomeMy WebLinkAboutFMC 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. AEr:rO *t1-tt'l1E1t E" EEUf'{IjAriE EAHEELIFIELIT r::A t'lriR '7, :ltrt4 E : tE Ht'1 = i';,i'llill.i ETHT t_tl] FlEF,,tiFlT L 1 .1 : Fl_lEr irL.HF,t'1 8",,'ETEI.,1 EETLIF. f'i*F, 7. :r-r!4 t:i ; t:itl Hl.1 5'r'5TEl,1 l-ll,l I TFi ll ,= Fi'r'ITEI'1 I- " f,lr_,' LtHi ;E El,lriL I5H S"r'HTEl,] trATE T I t'1E F,:-iEI.1rT f,,lr-il,l Irf],,,,,i,,,,,,r,, HH :l,,ll,,l :il: :,1,1 HR[:l-t s11-9,'1"1 1Et 1! E. EtFlut{tr*r:;E B|];IERFF I ELtr i_rrr H -t'Fl,i-iTlir,l't il . 11E 1r-;HTp,pfr_rlsl{:r1,1 Hi_rlJRg; 1! 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HI'1 T tlt :Ftl,lE|.,,] t)EL HlGH l.lHTER HLHFlll st,Ft ILt . !u1T 1|]:l:r5 Hl,l I"lHFl iE' IlllT !:l:lE, HI''] {-I,'IERF I LL HLHFiI'1 .-'tHl'l E. !lJ!1 1U:tT HI'i IrEi-r 18. llJ1E !:Ll5 Hl'1 riF,R I [t .. lt] 1 ? '1 I 51,! HI'1 L,-\t,,,1 FrEil[.rUr:rT fi LAF]l'1(-lr,tT 2. :l:l 1'l 1u:1E Hl',1 HPR 1U, lIJlT T;4I:I F'I'1 HI,E lLt , lltlT 7:48 *11 i:jutrtrElll LllFjlj HLARI''1 trEr:] 1 l:l .. ltll'f, 'J : Ut AI'1 t,,lit,\./ 11. IUI,J 1:1[t HI,,l t,li:l\./ 1t-_r, ll:ltlr iLl :1T Hl'1 HI(,;H F'E,J[)r-lr_]T ffLHRI'i ,t )i_rT :. lllM ll: I'1 Al'1 l'lH"I,' t[r ' tulE 12:lT Ft'1 f.l*R ltj . in I T :r : U: *t,1 I l,l,tHlitr FljEL LE\,,rEL HI.R 1l_1 . lul? T:4T HI"1 I,1HF':El . llr 1T 11:1T Ht'1 t.lHFl i1. 2Lr1T 1!:11 Pl'1 5,p,],;}gE ilt-lT ALARI'1 HIST{]EY REPOET ---_ I I.I_TANH ALAET.I T 4: xx}**Elrlt] H*nx* HLHFII'I H I 5T':-i'F."r' FIEF'(,IF'T i:;E l'.lri,ilR HLHFIt''1L 1:tl7 HI,ll'lLlLHF' Hf,,ll\lI-ILHR EF,ALTE H 1r,;H L 1L]I-I I TI HLHF.I,1f'lgFl ?. llltlj ':l r 4ll Ht1 Lilll L I rll-ll [i ALARI'It'1iF. T . !l:l!l-r 9: "trll Al''1 HII-;H LII.II.I ITI HLHRI'i FEE 1r,. 2Ll!': 1 l:l : l-1.1 HI',1 fir**xEl,lf,r Xx*xri .lHl'l ._'rAf! 1,1 hl ',tHlt !rtt 1lLl! 1lU! 1 n fl 1 Ll :43 HI"1 1r:l : !7 Hl'1 10:18 ill.l H I r.-;H t,,,lnTEE l,tHFil"l I l!t:; *5',p 1rJ., 'itl 1? 1U:05 Hl''l I,1gE lrl . !l:l 1 T ',l : LIE Ht',',1 trEL I \,JEF."i' I'lEE[iEtr,tJi::T !. llJl:r 1lJ:1E, Hl'1 AF'R 1[I . tLI 1T T:48 HI'1 l'.lilR ilj. lll 1? 1 1 : 1? Hl'1 1-ilL,,.l TEl"1F, lilHRl"l lI'li:; t)r-rT !, tU1! t:5! t't'1 t,lHR lll . lll 1? !:U! 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REF.'I:)FIT FiE l,,ll-j,tJFt iil*Ftl1L r:, : t) 1l:F, rl-4 :* 1 EI,lliR [r I EF'Efl]i:jEFr FtHlll L(-il,,,l LIr:l_l IIr HLHRIi Hl_lr_; lrl . lr:rlt 7: 1 1 F,1,,1 L{:il,,,l L 1r;U I It HLHF.ltlHF'FI 5. llrlS E : [r'] HI'i L'r:it"l LIr.il_l II.r HLAF.l,'l HF,Fi il .. :t_l!ijt t, : :T iilj 5E l,iFi,l-iFl,l-l LIT HLHFll.i I'1Hr i:lll . lll l l:l 'J : IF, gl.1 +xxxxEl,ltlxx*Xx i.xixxEl,l[] +*]ni ALAF]I,1 H I I:]T'I-I'E"r' F]EF'4-IRT HLhF,ll HISTi-1,8",' REF,i-)F.T 5EI,l5,l]R HLHFII'1L i, :[r]5F, 1-: i-1 l-_1,11-iFr [r ] -t,Et,.,l-'EF F,- t,,1 EEI,lS,i:iF.j,:rLlT *LAFtt'1f'1HF ?. ltlzt:r 1t:t :41 trtl L.i-iI.,.I LIULI ITr AL*RI.1 -- EEi'1ir,-iR i-iLHF.l lL l:l :[.r IFiF' T-l:l !-l iil']i:rFl T] I EF,E I,ISEF, F,It I,,1 L,t:rt.,,J LIr.lr_t I[r fiLHEf'l i-]r_rT r:rlr , ir_l!:J ljl : El:l t'f,1 Li:il,,,l L I r.jrl-l 1[. HLi.tFll'1 r-ir-:T :rU. lt:Liii 1!:4n F'l'l 1_;11,,,1 ltr.Jt_l IIr ALf,Ftl,1 ,t:)r-rT tlill . llllll 1!:l:i5 F'l'l tsLlEL nLHF,l'lf'lnE T. llrlij 1r:r :r:ri Ht'l -+xxfEI'llrr+xtf *LAEI'1 HIETOFI'/ EEF'(]ET SENE+E ALITEI'1L 9:tltEF' 9-1tr 2-1 SN,sE trlSPEI'ISEE PAN LTIIiJ L IQU I T] flLARI'1 DELI 16, E023 5 : [5 Ftt'l LOt'l LIGIUID tlLFtRt'1 DEC 1 6. ?-i23 7 : 4E, Al"1 LCIL] LIOUID ALAEI-I IlEr-r I .5, l[Zi] 6 : 14 nl'1 xxxrxEI"l[firrx+ xxiixXEl,lttxrx}){ixx*xEl''llixxii HLHF.I'1 H I =Ti-iFl'i" F:El''i iFlT t:EI,l={-LFl HLrilil'1 L1[r :[:]5t' 1l-1::-l it,ll-iE [r I l-iF,E l"]t-lEF' t,'H l"l r:iE I'll:j'l:rFl U l-lT HLrlFlt'l I,1HE T . !t:[t] l|_t : 41 Ht.1 L,t:)|,,J Llr,.il-lltr HLHEI.II'lnR 7. .t:t!:r 'l: Ei, rrl''l FLIEL IiL*RI'I I'1HR 7. lt:tltl t:55 HI'1 HLI'iFII"] H 1 ET(.IF]'/ REF',IJFIT EEI,lEOR riLAF,I'1 L1 1 :tilEF' 1l-l-1.1 i-1 EI,lEFl TI lsT'EI,,J-EF F' I,,] L,i-rr,,J L 1r.;1r_r l tr ALAFII''I i-tr.:T !'T. !l_li:J 1i:I! HI'l L,r-)1,,,1 LIl.11_l ltr riLHFJl'l 'iji:rT !8. It_l!t:r E : 54 Hli EEI,]E(.I,FI TILIT HLHRI'1 f'1HFt ?. ltJlij 1[:'l 1 Ht'1 nl-sFll,l 11 Il-j'I ,:-iF.'i FIEI .lf.lT irEl'lij'i-iFl HLHFII''i LltrtrlEF' 15-1ri i-1 ill'l'-:lF. tr ISt'EI'IEEE F'F]l"l 1;91,1;;I_iF. {-rLlT HLHRI'.1 f''lHE i.ILl!::] 1l:l :41 HI'l L,}!J LIr.;11-llI] HLlrFll'1 f.1HFr T. !lJ!:] 9: Eq r-il'l FI.IEL HL*RI,1I'IAF T. llllll 'l: E4 Al1 HLHF:['1 H I i:lT'l-)R"i" REF'l-iFlT 5;E1rlgr,LF, HLAFII'1 I- 1 ljl : ET UI'ILEAI Etl l-iTF' :- 1 g;1p' lt_['lF, ljEllE,i:i,F.,1:)LlT HLHFII'1 I'1HF. T, iUllj 1 l:l : "l I Hi'1 L'i-)r,,,] L I i.]l ll tr *LAFll,l I,1AF] T. lllllj '!:"tr1 Hl"1 FLIEL HLBFII'I f,18Fl 7 , il-llljl 'l : 4l:l HI"l ALHFII'1 HIST+R'r' EEPilFiT FEI{E{}F ALAFI'1L14:87 FILL T-1 sI,]FJF F, lPIl"lil gutlF FUEL AL*RI.1 FEE 18. 2ltt4 ? :rlt pt'l FUEL *LAEI"IFEE 1 , lt_1t4 5: 1X F,t'1 FUEL ALAEI'IJ*l'l lZ, :Dl4 5 : 116 Ht'1 + * i * * ff',,lf.r ir fr ii i i HLHFII'1 H I I:lT(-lR"i" FE['{,rET 5El,l5i:rFl HLAFll.lL1I:'l 1 F'RE|'1 Il-ll'1 l:rTF :-1 I:;TP SLll''lF l:rEl,lE(:iFt {:tl_lT HLHRl.ll'lHFl T. !Lt!t:1 ll:t :41 Hl'1 L'i-iL,J Llr.il-l If,r HLHRt"ll'1HFl 7 , llllt:r t: 4t Hl"l FIIEL rLARI'1I'i*Fl T. lrllrjr 'l:.lr:i Hl,'] XxiXXEf,lti**rriinX*XEI,ID*inin i+ir*EI,lItxx*it HLiiF]I'1 H I l]lT'i iF,'i' REF.I }IIT 5Et,]t:iilI{ HLHFtf"l L 1 E : 't 1 t,FEt,l I Llt,l liTI, !* 1 Fi',TF' lfLll''lF' SEI'lFiUR ill_lT HLHF,l,ll,lHFr T. llilr:t 1 Lt : 41 HI'l L,t_rlil LIr..lulti HLItFll,lf'lAFt T, lr--tr't:r I : 4'! *1,1 FIJEL ITLHEI'I |'1HFJ T . ll:l!r:r t:4rl HI,'l XiiXXEI,lt., XXiXX HLAFII,] H I ETi-I,F,.,i, FEF,'I],F]T EEtl='r_rR HLHFit'1L1E:'11 FILL !-1 pr i gr 1 1lr.-; ;:j l_l[.1t1 L{:il,,,l LIiill_l IIr uLHRl.j L,rgt-: lii . ltlllj L, :5'i t,li FUEL HLAEI.I f'1HF, T. llrlri i:4! F,1.1 5EI',lE(:iFl 0LlT HLHRI,II''lAFl ?. !ll:t:t 1 ll : 41 HI'l ALriFll j HIl:T,ir,Fl,i' FlEF,,t:rFlT =E l,,1E,i-)E i:iLHFll,1L 1 T :[r I EiiEL tiTt, !- 1sTP EI- .1F, FI-IEL HLHF]I,1,ll-ll !':r . lltlljl E: t_t? Hl,1 IJEI,]EtiR LIUT, HLHEI'If'1ilE 7. ll-lit:t 1r,r :41 u,,,, L,t_rri LIr.iuiIr ALHRI'1I'1HR T, trjlt t ; 4E Al,1 iiixrEI,,JI]+xriI HLAF]I'1 H I sTi:IF,,i, F,EF,,I-IFIT EEIIEi],F] fjLHRI,I L1 Lr :trl EF-rEL FI LL :,- II, I F, I l,lr:; li L['lF,Fl-lEL HLi:lRl,l I'1HF. 1 r:r , lltll] :1 : tjjE I,1,1 EEI,IEiIE LlI]T HLHF]I'If,'lHE ?. ill:t 1t_l ;.1 1 rit,1 L,r-:'1,,1 LIr.tUitr HLHF.t'jl'l|tE 7. !t_lr-l !:4E, At,1 AL*F]I.l HISTOFI'/ EEFOET 5EI'{E+E *LftEt'1L1g r OTHER FJEI',ISUFF xx**IEND*xrrx HL*RI'I H IST'|]RY REF,{-IFIT 5EI'lE,i-rR HLHFtl.l L:r:l : r_iT HER t-iE l,]E i-iF]l-j irrIXXEMi:+iir* HLHFI'1 H I FJT,i-iF]'i' F.EI,,I.}F.]T ltf t,ll_li_jFl HliiFll,,l _ L 1 : tt? 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BRUNDAGEBSSR INC661-588-2777DSLDSL13-1415-16PRODUCTPRODUCTNATHAN HOLMAN 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 ✔ 3/7/24 ARCO BRUNDAGE 1819 E. BRUNDAGE BAKERSFIELD 93307 BSSR INC 661-588-2777 6630 ROSEDALE HWY NATHAN HOLMAN 672812 8111067 8/23/24 FRANKLIN 7/18/24 HYDROSTATIC 1 HR SPILL BUCKETS 3/7/24 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. ✔ ✔ 87-1 87-2 91 DSL EBW EBW EBW EBW ✔✔✔✔ ✔✔✔✔ ✔✔✔✔ ✔✔✔✔