HomeMy WebLinkAboutFMC 2024CERS = 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
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
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
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
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.
SHEAR VALVE OPERATION INSPECTION
Facility Name: Owner
Address: Address
City, State, Zip Code: City, State, Zip Code:
Facility I.D. #:e #:
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 poppet valve ?
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
-
Test Results Pass
Fail
Pass
Fail
Pass
Fail
Pass
Fail
Pass
Fail
Pass
Fail
Pass
Fail
Pass
Fail
Pass
Fail
Comments:
Name (print) Signature
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I10100
OCT 30, 2024 12:27 PM
CIRCLE K 2701270
5634 STINE RD.
BAKERSFIELD, CA
80749873405001
SYSTEM STATUS REPORT
ALL FUNCTIONS NORMAL
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I20100
OCT 30, 2024 12:27 PM
CIRCLE K 2701270
5634 STINE RD.
BAKERSFIELD, CA
80749873405001
IN-TANK INVENTORY
TANK PRODUCT VOLUME TC VOLUME ULLAGE HEIGHT WATER TEMP
1 UNL-REG(005) 6701 6613 7724 55.59 0.00 78.71
2 UNL Premium 5665 5571 6184 56.45 0.00 83.63
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I51700
OCT 30, 2024 12:27 PM
SYSTEM TYPE AND LANGUAGE FLAG
SYSTEM UNITS
U.S.
SYSTEM LANGUAGE
ENGLISH
SYSTEM DATE/TIME FORMAT
MON DD YYYY HH:MM:SS xM
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I50F00
OCT 30, 2024 12:27 PM
MON DD YYYY HH:MM:SS xM
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I60100
OCT 30, 2024 12:27 PM
TANK CONFIGURATION
DEVICE LABEL CONFIGURED
1 UNL-REG(005) ON
2 UNL Premium ON
3 OFF
4 OFF
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<9999FF1B>
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I60200
OCT 30, 2024 12:28 PM
TANK PRODUCT LABEL
TANK PRODUCT LABEL
1 UNL-REG(005)
2 UNL Premium
3
4
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<
I60300
OCT 30, 2024 12:28 PM
TANK PRODUCT CODE
TANK PRODUCT LABEL
1 UNL-REG(005) A
2 UNL Premium B
3 3
4 4
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<
I60400
OCT 30, 2024 12:28 PM
TANK FULL VOLUME
TANK PRODUCT LABEL GALLONS
1 UNL-REG(005) 14425
2 UNL Premium 11849
3 0
4 0
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<
I60700
OCT 30, 2024 12:28 PM
TANK DIAMETER
TANK PRODUCT LABEL INCHES
1 UNL-REG(005) 117.75
2 UNL Premium 117.75
3 0.00
4 0.00
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<
I60900
OCT 30, 2024 12:28 PM
TANK THERMAL COEFFICIENT
TANK PRODUCT LABEL
1 UNL-REG(005) 0.000700
2 UNL Premium 0.000700
3 0.000000
4 0.000000
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<
I61200
OCT 30, 2024 12:28 PM
TANK MANIFOLDED PARTNERS
TANK PRODUCT LABEL SIPHON MANIFOLDED TANKS LINE MANIFOLDED TANKS
1 UNL-REG(005) NONE NONE
2 UNL Premium NONE NONE
3 NONE NONE
4 NONE NONE
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<
I62100
OCT 30, 2024 12:28 PM
TANK LOW PRODUCT LIMIT
TANK PRODUCT LABEL GALLONS
1 UNL-REG(005) 1084
2 UNL Premium 900
3 0
4 0
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<
I62200
OCT 30, 2024 12:28 PM
TANK HIGH PRODUCT LIMIT
TANK PRODUCT LABEL GALLONS
1 UNL-REG(005) 13704
2 UNL Premium 11257
3 0
4 0
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<
I62300
OCT 30, 2024 12:28 PM
TANK OVERFILL LEVEL LIMIT
TANK PRODUCT LABEL GALLONS
1 UNL-REG(005) 12983
2 UNL Premium 10664
3 0
4 0
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I62400
OCT 30, 2024 12:29 PM
TANK HIGH WATER LEVEL LIMIT
TANK PRODUCT LABEL INCHES
1 UNL-REG(005) 2.5
2 UNL Premium 2.5
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<
I62800
OCT 30, 2024 12:29 PM
TANK MAXIMUM VOLUME LIMIT
TANK PRODUCT LABEL GALLONS
1 UNL-REG(005) 14425
2 UNL Premium 11849
3 0
4 0
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<
I62900
OCT 30, 2024 12:29 PM
TANK DELIVERY REQUIRED LIMIT
TANK PRODUCT LABEL GALLONS
1 UNL-REG(005) 1443
2 UNL Premium 948
3 0
4 0
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<
I70300
OCT 30, 2024 12:29 PM
LIQUID TYPE
SENSOR LOCATION TYPE
1 87 ANNULAR TRI-STATE (SINGLE FLOAT)
2 87 TURBINE TRI-STATE (SINGLE FLOAT)
3 91 ANNULAR TRI-STATE (SINGLE FLOAT)
4 91 TURBINE TRI-STATE (SINGLE FLOAT)
5 UDC 1-2 TRI-STATE (SINGLE FLOAT)
6 UDC 3-4 TRI-STATE (SINGLE FLOAT)
7 UDC 5-6 TRI-STATE (SINGLE FLOAT)
8 UDC 7-8 TRI-STATE (SINGLE FLOAT)
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<
I20600
OCT 30, 2024 12:29 PM
CIRCLE K 2701270
5634 STINE RD.
BAKERSFIELD, CA
80749873405001
TANK ALARM HISTORY
TANK 1 UNL-REG(005)
LOW PRODUCT ALARM MAR 17, 2024 3:46 PM
DEC 25, 2023 11:24 AM
DEC 3, 2023 3:11 PM
DELIVERY NEEDED SEP 22, 2024 4:09 PM
JUN 10, 2024 8:07 AM
MAY 28, 2024 10:33 AM
TANK 2 UNL Premium
PROBE OUT JAN 3, 2024 3:37 PM
TANK 5
TANK 6
TANK 7
TANK 8
TANK 9
TANK 10
TANK 11
TANK 12
TANK 13
TANK 14
TANK 15
TANK 16
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I30200
OCT 30, 2024 12:29 PM
CIRCLE K 2701270
5634 STINE RD.
BAKERSFIELD, CA
80749873405001
LIQUID ALARM HISTORY REPORT
SENSOR LOCATION
1 87 ANNULAR
OCT 30, 2024 9:09 AM FUEL ALARM
OCT 30, 2024 9:09 AM FUEL ALARM
OCT 30, 2024 9:08 AM FUEL ALARM
2 87 TURBINE
OCT 30, 2024 8:53 AM SENSOR OUT ALARM
OCT 30, 2024 8:47 AM FUEL ALARM
OCT 23, 2023 9:33 AM SENSOR OUT ALARM
3 91 ANNULAR
OCT 30, 2024 8:53 AM SENSOR OUT ALARM
OCT 30, 2024 8:50 AM FUEL ALARM
OCT 30, 2024 8:48 AM FUEL ALARM
4 91 TURBINE
OCT 30, 2024 8:53 AM SENSOR OUT ALARM
JAN 10, 2024 8:31 AM FUEL ALARM
JAN 10, 2024 8:26 AM FUEL ALARM
5 UDC 1-2
OCT 30, 2024 8:53 AM SENSOR OUT ALARM
OCT 30, 2024 8:43 AM FUEL ALARM
OCT 23, 2023 9:32 AM SENSOR OUT ALARM
6 UDC 3-4
OCT 30, 2024 8:53 AM SENSOR OUT ALARM
OCT 30, 2024 8:44 AM FUEL ALARM
OCT 23, 2023 9:32 AM SENSOR OUT ALARM
7 UDC 5-6
OCT 30, 2024 8:53 AM SENSOR OUT ALARM
OCT 30, 2024 8:45 AM FUEL ALARM
OCT 23, 2023 9:32 AM SENSOR OUT ALARM
8 UDC 7-8
OCT 30, 2024 8:53 AM SENSOR OUT ALARM
OCT 30, 2024 8:45 AM FUEL ALARM
OCT 23, 2023 9:32 AM SENSOR OUT ALARM
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I31600
OCT 30, 2024 12:29 PM
CIRCLE K 2701270
5634 STINE RD.
BAKERSFIELD, CA
80749873405001
SMART SENSOR ALARM HISTORY REPORT
SENSOR LOCATION
1 DISP 1-2 AFM
AUG 8, 2023 2:31 PM COMMUNICATION ALARM
AUG 8, 2023 9:25 AM COMMUNICATION ALARM
JUL 14, 2022 11:01 AM COMMUNICATION ALARM
2 DISP 3-4 AFM
AUG 8, 2023 2:33 PM COMMUNICATION ALARM
AUG 8, 2023 9:24 AM COMMUNICATION ALARM
3 DISP 5-6 AFM
AUG 8, 2023 9:23 AM COMMUNICATION ALARM
4 DISP 7-8 AFM
AUG 8, 2023 2:32 PM COMMUNICATION ALARM
AUG 8, 2023 9:30 AM COMMUNICATION ALARM
5 DISP 1-2 VPS
AUG 8, 2023 9:23 AM COMMUNICATION ALARM
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<
I10100
OCT 30, 2024 12:30 PM
CIRCLE K 2701270
5634 STINE RD.
BAKERSFIELD, CA
80749873405001
SYSTEM STATUS REPORT
ALL FUNCTIONS NORMAL
>
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I90200
OCT 30, 2024 12:30 PM
SOFTWARE REVISION LEVEL
VERSION 336.02
SOFTWARE# 346336-100-C
CREATED - 21.02.13.11.53
S-MODULE# 330160-004-a
SYSTEM FEATURES:
PERIODIC IN-TANK TESTS
ANNUAL IN-TANK TESTS
ISD/APM
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