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Home My WebLink About2024 FMCAppendix 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. Monitoring System Certification UST Monitoring Site Plan sire Address: 4101 Truxtun Avenue, Bakersfield, CA. 93301 .5';? . 1e^*t5 7\\3!r..- ?n9 v0q :qnr.i:. . 33ca,l I - c,., i il,..r"r+. 5do.'s 7iq t(o -q rq ii ,,,.,,,, 87 :: a$ oo. \oAae'36 03-.TIli!.. f Lu -.?<' 1'a6getz' fu't't" Date map was drawn', _l_l Instructions If you already have a diagram that shows all required information, you may include it, rather than this page, with your Monitoring System Certification. On your site plan, show the general layout of tanks and piping. Clearly identifo locations of the following equipment, if installed: monitoring system control panelsi sensors monitoring tank annular spaces, sumps, dispenser pans, spill containers, or other secondary containment areas; mechanical or electronic line leak detectors; and in-tank liquid level probes (if used fbr leak detection). In the space provided, note the date this Site Plan was prepared. Page 4 of 4 www.unidors.orgt'N-036 {/{Ite\. 0l/lll08 04 30 24 CVE Cal- Valley Equipment 3500 Gilmore Ave. Bakersfield CA 93308 661 -327-9341 FAX# 661 -325-2529 VAPORLESS MANUFACTURING, INC. LDT-890 Leak Detector Test Record Technician Date Pass / Fail Product Manufacturer Leak rate Operating pressure Line pressure (pump off) Facility Address Bleed back (pump off) Step through time to full flow Stays in leak search position SHEAR VALVE OPERATION INSPECTION Facility Name: Owner Address: Address City, State, Zip Code: City, State, Zip Code: Facility I.D. #:Owner Phone #: Testing Company: Phone #: This data sheet is for inspecting shear valves located inside dispensers. See PEI/RP1200 Section 10 for the inspection procedure. Product Grade Dispenser ID# Shear ValveType (Product/Vapor) 1. Is the shear valve rigidly anchored to the dispenser box frame or dispenser island? Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No 2. Is the shear section posi- tioned between ½ inch above or below the top surface of the dispenser island? Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No 3. Is the lever arm free to move?Yes No NA Yes No NA Yes No NA Yes No NA Yes No NA Yes No NA Yes No NA Yes No NA Yes No NA 4.Does the lever arm snap the the poppet valve shut? Yes No NA Yes No NA Yes No NA Yes No NA Yes No NA Yes No NA Yes No NA Yes No NA Yes No NA 5. Can any product be dispensed when the product shear valve is closed? Yes No NA Yes No NA Yes No NA Yes No NA Yes No NA Yes No NA Yes No NA Yes No NA Yes No NA A “No” to Lines 1-4 or a “Yes” for Line 5 indicates a test failure. Test Results Pass Fail Pass Fail Pass Fail Pass Fail Pass Fail Pass Fail Pass Fail Pass Fail Pass Fail Comments: Tester’s Name (print) Tester’s Signature Reference PEI/RP1200-19 Appendix C-10 Date: Latest Version 3/14/2022 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 ☐ 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 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. CVE Cal- Valley Equipment 3500 Gilmore Ave. Bakersfield CA 93308 661 -327-9341 FAX# 661 -325-2529 VAPORLESS MANUFACTURING, INC. LDT-890 Leak Detector Test Record Technician Date Pass / Fail Product Manufacturer Leak rate Operating pressure Line pressure (pump off) Facility Address Bleed back (pump off) Step through time to full flow Stays in leak search position