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Home My WebLink AboutREPAIR 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 10137943 03/19/2024 Jaco #3367 Fastrip #640 (East) 8001 White Lane Bakersfield 93309 Nwestco LLC (800) 339-9930 2209 Zeus Court, Bakersfield, CA 93308 Billy Lane 1073967 10281488 03/15/2025 Veeder-Root C33867 8/4/2024 03/19/2024 5Billy Lane 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 T TLS 350 CURRENT 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 L5 208 87 SIPHON FILL 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. ܆܆ Replacement in 87 siphon tank on west side. Tested, passed. 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. NO PARKINGNO PAR KING EXISTING BUILDING L13 L14 L15L16 L17 L18 L12STP L9STP L6STP L3STP L10 L7 L4 L1 L11 L8 L5 L2 87-2 UNLEADED 12,000 GALLON87-1 UNLEADED 12,000 GALLON DIESEL12,000 GALLON 1/2 43 65 910 78 12/11 #3-366 #3-367 N 91 PREMIUM12,000 GALLON V F 87-1 UNLEADED12,000 GALLON 87-2 UNLEADED12,000 GALLON91 PREMIUM12,000 GALLON DIESEL12,000 GALLON L5STP L2STP L11STP L14STP AL6 L1 L10 L13 L7/L8 L3 L12 L15 L9 L18 L17 L16L19 L20 L21 18/17 1516 1314 2122 1920 25/24 L22 PROPERTY LINE PROPERTY LINEH W W H PRICE SIGN PRICE SIGNDIESEL PRICE SIGN #367 #366 NO PARKINGACCESS RAMPS ACCESSRAMPDUMPSTER G A A A V F V F F A A A A A F F F F V V V 366 LEGEND L1 87-1 ANNULAR L2 87-1 FILL L3 87-1 STP L4 87-2 ANNULAR L5 87-2 FILL L6 87-2 STP L7 91 ANNULAR L8 91 FILL L9 91 STP L10 DSL ANNULAR L11 DSL FILL L12 DSL STP L13 UDC 1 - 2 L14 UDC 3 - 4 L15 UDC 5 - 6 L16 UDC 7 - 8 L17 UDC 9 - 10 L18 UDC 11 -12 367 LEGEND L1 87-1 ANNULAR L2 87-1 STP ANNULAR AND SUMP SENSOR 2-TO-1 L3 87-1 FILL L5 87-2 STP L6 87- 2 STP ANNULAR L7 87-2 FILL L8 87-2 ANNULAR FILL L9 87-2 ANNULAR L10 91 ANNULAR L11 91 STP L12 91 FILL L13 DSL ANNULAR L14 DSL STP L15 DSL FILL L16 UDC 13 - 14 L17 UDC 15 - 16 L18 UDC 17 - 18 L19 UDC 19 -20 L20 UDC 21 -22 L21 UDC 23 - 24 L22 VENT BOX ANNULAR AND SUMP SENSOR 2-TO-1 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 3/2 INCH DOUBLE WALL PIPE VAPOR VENT 2 INCH SINGLE WALLED PIPE S1: 87-2 UNLEADED VENT LINE S2: PRODUCT SIPHON LINE AND VACUUM CHASE S3: VAPOR RETURN LINE EMERGENCY SHUT-OFF OVERFILL ALARM PRODUCT SPILL CONTAINER VAPOR SPILL CONTAINER ANNULAR FIRE EXTINGUISHER WATER METER SHUT-SHUT OFF HEALY CAS EVACUATION MEETING POINT CIRCUIT BREAKER AUTOMATIC TANK GAUGE AIR AND WATER DISPENSER HAZWASTE DRUM WH A F V SITE MAP DATE REVISIONS DATE: DRAWN BY: CHECKED: APPROVED: RAC CADFILE: SHEET NO. A.P.N.:385-013-21-4 SCALE: CONVENIENCE MARKET FOR: 3101 STATE RDBAKERSFIELD, CA 93308 PROJECT OWNER: DRAWING: CD FASTRIPS - 3-366-3-367 3366-MSP FASTRIP FOOD STORE BAKERSFIELD, CALIFORNIA 933098001 WHITE LN. JACO HILL SITE PLAN C1 TAB:CERS 1"=15'-0" INCHES012 SHEET SIZE 22 X 34 01/07/2022 8001 WHITE LN. BAKERSFIELD, CA 93309 GOSFORD RD. WHITE LN. PROJECT OWNER: JACO HILL PO. BOX 82515 BAKERSFIELD, CA 93380 CONTACT: SITE PLOT PLAN FOR: FACILITY ID 15-021-097250 CERS ID 10137946 FASTRIPS 3-366 / 3-367 8001 WHITE LN. BAKERSFIELD, CA 93309 02/12/2021 REV. VICINITY MAP PROJECT DATA