The URL can be used to link to this page

Home My WebLink AboutFMC 2024 (INSTALL START UP) 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 5 TYPE OF ACTION ☐ Installation ☐ Repair ☒ 12 Month 1. FACILITY INFORMATION CERS ID 10957798 Certification Date 6/19/2024 Facility Name Sully's Heath Facility Address 16101 Stockdale Hwy. City Bakersfield ZIP Code 93314 2. SERVICE TECHNICIAN INFORMATION Company Performing the Certification Advanced Compliance Phone 661-706-4321 Mailing Address 4007 Brae Burn Dr Bakersfield Ca. 93306 Service Technician Performing Test Bruce W. Hinsley Contractor/Tank Tester License Number 971259 ICC Number 8032698 ICC Expiration Date 6/26/2025 3. TRAINING AND CERTIFICATIONS Manufacturer and Test Equipment Training Certifications Expiration Date Veeder-root 4/21/2026 Redjacket LLD 1/6/2026 VMI 1/6/2026 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 6/19/2024 Total # of Pages 5 Underground Storage Tank Monitoring System Certification Form Page 2 of 5 5. MONITORING SYSTEM AND PROGRAMMING A separate Monitoring System Certification Form must be prepared for each control panel. Make of Monitoring System Control Panel Veeder-Root Model of Monitoring System Control Panel TLS-450 Software Version Installed Attach the post-certification reports if the monitoring system is capable of generating either; X Monitoring System Set-up X Alarm History Report Yes No NA All monitoring equipment is operational per manufacturer’s specifications? X ☐ Secondary containment systems are free of damage, debris, or liquid? X ☐ Are the audible and visual alarms operational? X ☐ All sensors have been: 1) visually inspected for wiring kinks, breaks and residual buildup on floats; and 2) tested for functionality and confirmed operational? X ☐ ☐ Are all sensors installed to detect a release at the earliest opportunity in the secondary containment? X ☐ ☐ The monitoring system set-up was reviewed, and proper settings confirmed? X ☐ ☐ Was the monitoring control panel’s backup battery visually inspected, functionally tested, and confirmed operational? X ☐ ☐ Does the flow of fuel stop at the dispenser if a release is detected in the under- dispenser containment? X ☐ ☐ Does the turbine automatically shut down if the piping secondary containment monitoring system fails to operate or is electrically disconnected? X ☐ ☐ 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) X Sump X UDC X ☐ ☐ If monitoring system alarms are relayed to a remote monitoring center, is all communication equipment operational? ☐ ☐ X 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 5 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 L-1 794380-208 87 Fill Sump X ☐ L-2 794380-304 87 Fill Sump Annular X ☐ L-3 794380-208 87 STP Sump X ☐ L-4 794380-304 87 STP Sump Annular X ☐ L-5 794380-208 91 Fill Sump X ☐ L-6 794380-304 91 Fill Sump Annular X ☐ L-7 794380-208 91 STP Sump X ☐ L-8 794380-304 91 STP Sump Annular X ☐ L-9 794380-208 Diesel Fill Sump X ☐ L-10 794380-304 Diesel Fill Sump Annular X ☐ L-11 794380-208 Diesel STP Sump X ☐ L-12 794380-304 Diesel STP Sump Annular X ☐ L-13 794380-208 UDC #1-2 X ☐ L-14 794380-304 UDC #1-2 Annular X ☐ L-15 794380-208 UDC #3-4 X ☐ L-16 794380-304 UDC #3-4 Annular X ☐ L-17 794380-208 UDC #5-6 X ☐ L-18 794380-304 UDC #5-6 Annular X ☐ L-19 794380-208 UDC #7-8 X ☐ L-20 794380-304 UDC #7-8 Annular X ☐ L-21 794380-208 UDC #9-10 X ☐ L-22 794380-304 UDC #9-10 Annular X ☐ L-23 794380-208 UDC #11-12 X ☐ L-24 794380-30479 UDC #11-12 Annular X ☐ 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 5 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 L-25 794380-208 UDC #13-14 X ☐ L-26 794380-304 UDC #13-14 Annular X ☐ L-27 794380-208 UDC #15-16 X ☐ L-28 794380-304 UDC #15-16 Annular X ☐ L-29 794380-208 Vent Pan X ☐ L-30 794380-304 Vent Pan Annular X ☐ S-1 857280-100 87 Product Line X ☐ S-2 857280-100 87 Vent Line X ☐ S-3 857280-200 87 Tank Annular X ☐ S-4 857280-100 87 Vapor Line X ☐ S-5 857280-100 91 Product Line X ☐ S-6 857280-100 91 Vent Line X ☐ S-7 857280-100 Diesel Product Line X ☐ S-8 857280-100 Diesel Vent Line X ☐ S-9 857280-200 91-Diesel Tank Annular X ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ 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 5 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.) X 3 GPH ☐ 0.1 GPH ☐ 0.2 GPH Yes No NA Has the testing apparatus been properly calibrated? X ☐ ☐ For emergency generator tank systems, does the LLD create an audible and visual alarm when a leak is detected? ☐ ☐ X For mechanical LLDs, does the LLD restrict the flow through the pipe when a release is detected? X ☐ ☐ For electronic LLDs, does the turbine automatically shut off when a release is detected? ☐ ☐ X For electronic LLDs, does the turbine automatically shut off if any portion of the monitoring system is disabled or disconnected? ☐ ☐ X For electronic LLDs, does the turbine automatically shut off if any portion of the monitoring system malfunctions or fails a tightness test? ☐ ☐ X For electronic LLDs, have all accessible wiring connections been visually inspected for kinks and breaks? ☐ ☐ X Were all items on the equipment manufacturer’s maintenance checklist completed? X ☐ ☐ Were all LLDs confirmed operational within regulatory requirements? X ☐ ☐ LLD ID LLD Model Lines Monitored Pass Fail 87 FX-1V 87 X ☐ 91 FX-1V 91 X ☐ Diesel FX-1DV Diesel X ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ 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 6 of 5 8. IN-TANK GAUGING TESTING X 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. FS1.01Sully'sC-Store New Fuel SystemTRASHTRASH 1" = 10'-0"PIPING LEGEND SENSOR MAP C-STORE Ver. 1.5 – 08.20.14 Shear Valve Operation Test CERS ID: 10957798 Test Company: Advanced Compliance Site Name: Sully's Heath Technician: Bruce W. Hinsley Site Address: 16101 Stockdale Hwy. Certification Number Expiration Date City: Bakersfield Zip: 93314 ICC (SERVICE TECH): 8032698 6/26/2025 Date/Time of Test: 6/19/2024 13:00 Product Grade Dispenser Number 1.Shear Valve Type (Product or Vapor) 2. Is the shear valve properly anchored? 3. Is the shear valve within ½ in of dispenser island? 4. Is the lever arm free moving? 5. Does the lever arm close poppet valve? 6. Can you Dispense with shear valve in closed position? Pass / Fail 87 1-2 Product Yes Yes Yes Yes No Pass 91 1-2 Product Yes Yes Yes Yes No Pass Diesel 1-2 Product Yes Yes Yes Yes No Pass 87 3-4 Product Yes Yes Yes Yes No Pass 91 3-4 Product Yes Yes Yes Yes No Pass 87 5-6 Product Yes Yes Yes Yes No Pass 91 5-6 Product Yes Yes Yes Yes No Pass 87 7-8 Product Yes Yes Yes Yes No Pass 91 7-8 Product Yes Yes Yes Yes No Pass 87 9-10 Product Yes Yes Yes Yes No Pass 91 9-10 Product Yes Yes Yes Yes No Pass 87 11-12 Product Yes Yes Yes Yes No Pass 91 11-12 Product Yes Yes Yes Yes No Pass 87 13-14 Product Yes Yes Yes Yes No Pass 91 13-14 Product Yes Yes Yes Yes No Pass Diesel 13-14 Product Yes Yes Yes Yes No Pass 87 15-16 Product Yes Yes Yes Yes No Pass 91 15-16 Product Yes Yes Yes Yes No Pass . Signature of Technician: ___________________________ Date: 6/19/2024 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 X Installation ☐ Repair ☐ 12 Month 1. FACILITY INFORMATION CERS ID 10957798 Test Date 6/19/2024 Facility Name Sully's Heath Facility Address 16101 Stockdale Hwy. City Bakersfield ZIP Code 93314 2. SERVICE TECHNICIAN INFORMATION Company Performing the Test Advanced Compliance Phone 661-706-4321 Mailing Address 4007 Brae Burn Dr. Bakersfield Ca. 93306 Service Technician Performing Test Bruce W. Hinsley Contractor/Tank Tester License Number 971259 ICC Number 8032698 ICC Expiration Date 6/26/2025 3. TRAINING AND CERTIFICATIONS Manufacturer and Test Equipment Training Certifications Expiration Date 4. TEST PROCEDURE INFORMATION Test Procedures Used Components Tested Industry Standard 87, 91 & Diesel 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 6/19/2024 Total # of Pages 2 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 X Industry Standard ☐ Professional Engineer Test Type ☐ Pressure ☐ Vacuum X Hydrostatic Tank ID 87 91 Diesel Spill Container Manufacturer: OPW OPW OPW Method of Cathodic Protection ☐ Nonmetallic X Other ☐ Nonmetallic X Other ☐ Nonmetallic X Other ☐ Nonmetallic ☐ Other Is the spill container minimum capacity five gallons excluding riser volume? X Yes ☐ No* X Yes ☐ No* X Yes ☐ No* ☐ Yes ☐ No* Method to keep spill container empty X Drain ☐ Pump ☐ Other X Drain ☐ Pump ☐ Other X Drain ☐ Pump ☐ Other ☐ Drain ☐ Pump ☐ Other Spill Container Test Results X Pass ☐ Fail X Pass ☐ Fail X 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. Advanced Compliance 4007 Brae Burn Drive Bakersfield, Ca. 93306 661-706-4321 VAPORLESS MANUFACTURING, INC. LDT-890 Leak Detector Test Record Contractor: Advanced Compliance Customer: Sullivans Heath Date: 6/19/2024 Location: 16101 Stockdale Hwy. Bakersfield, Ca. 93314 Product: 87 UL Technician: Bruce W. Hinsley Submersible Pump Identification Manufacturer: Redjacket Model No.: Serial No.: Notes: Leak Detector Identification Manufacturer: Redjacket Description: FX-1V Diaphragm-type: Piston-type: Tamper-proof seal installed: Other Style Leak Detector: Notes: Leak Detector in Submersible Pump Test at Dispenser Operating Pump Pressure (psi): 37 (para. 15) Gallons per hour rate: 3.0 (para. 22) Line pressure with pump shut off (psi):18 (para. 23) Bleed-back Test with pump off (ml): 320 (para. 26) Step-through time to full flow (secs): 3 (para. 30) Leak detector stays in leak search position (Yes/No): Yes (para. 42) Leak Detector Test Pass / Fail Notes: Pass *Complete thermal expansion test before failing leak detector Advanced Compliance 4007 Brae Burn Drive Bakersfield, Ca. 93306 661-706-4321 VAPORLESS MANUFACTURING, INC. LDT-890 Leak Detector Test Record Contractor: Advanced Compliance Customer: Sullivans Heath Date: 6/19/2024 Location: 16101 Stockdale Hwy. Bakersfield, Ca. 93314 Product: 91 UL Technician: Bruce W. Hinsley Submersible Pump Identification Manufacturer: Redjacket Model No.: Serial No.: Notes: Leak Detector Identification Manufacturer: Redjacket Description: FX-1V Diaphragm-type: Piston-type: Tamper-proof seal installed: Other Style Leak Detector: Notes: Leak Detector in Submersible Pump Test at Dispenser Operating Pump Pressure (psi): 37 (para. 15) Gallons per hour rate: 3.0 (para. 22) Line pressure with pump shut off (psi):18 (para. 23) Bleed-back Test with pump off (ml): 90 (para. 26) Step-through time to full flow (secs): 3 (para. 30) Leak detector stays in leak search position (Yes/No): Yes (para. 42) Leak Detector Test Pass / Fail Notes: Pass *Complete thermal expansion test before failing leak detector Advanced Compliance 4007 Brae Burn Drive Bakersfield, Ca. 93306 661-706-4321 VAPORLESS MANUFACTURING, INC. LDT-890 Leak Detector Test Record Contractor: Advanced Compliance Customer: Sullivans Heath Date: 6/19/2024 Location: 16101 Stockdale Hwy. Bakersfield, Ca. 93314 Product: Diesel Technician: Bruce W. Hinsley Submersible Pump Identification Manufacturer: Redjacket Model No.: Serial No.: Notes: Leak Detector Identification Manufacturer: Redjacket Description: FX-1DV Diaphragm-type: Piston-type: Tamper-proof seal installed: Other Style Leak Detector: Notes: Leak Detector in Submersible Pump Test at Dispenser Operating Pump Pressure (psi): 41 (para. 15) Gallons per hour rate: 3.0 (para. 22) Line pressure with pump shut off (psi):5 (para. 23) Bleed-back Test with pump off (ml): 50 (para. 26) Step-through time to full flow (secs): 3 (para. 30) Leak detector stays in leak search position (Yes/No): Yes (para. 42) Leak Detector Test Pass / Fail Notes: Pass *Complete thermal expansion test before failing leak detector