HomeMy WebLinkAboutFMC 2025Appendix 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.
UDC-1UDC-2
UDC-3UDC-4123456
78Diesel91 Premium87 Unleaded22,000 GALLONSUST-18,000 GALLONSUST-220,000 GALLONSUST-3TS-3TS-1TS-2FS-1FS-2FS-3AAVVVVDISPENSER UDC 1-2536 SENSORDISPENSER UDC 3-4536 SENSORDISPENSER UDC 5-6536 SENSORDISPENSER UDC 7-8536 SENSOR87 TURBINE SUMP536 SENSOR480 SENSOR99LD LINE LEAK DETECTORVACUUM SENSOR KIT #11-2-3-4-5-6-7-8 PRODUCT LINEDIESEL TURBINE SUMP536 SENSOR480 SENSOR99LD LINE LEAK DETECTORVACUUM SENSOR KIT #31-2-7-8 PRODUCT LINE91 TURBINE SUMP536 SENSOR480 SENSOR99LD LINE LEAK DETECTORVACUUM SENSOR KIT #21-2-3-4-5-6-7-8 PRODUCT LINE87 FILL SUMP536 SENSORDIESEL FILL SUMP536 SENSORPREMIUM FILL SUMP536 SENSORDIESEL ANNULAR303 SENSOR8791 ANNULAR303 SENSORHEALY CLEAN AIR SEPERATORVENTSUMPTRANSITION SUMP536 SENSORZONE # 1-87 REGULARZONE#4- 91 PREMIUMZONE #2- 87 VAPOR LINEZONE #3- 87 VENT LINEZONE #7- DIESEL VENT LINEZONE #5-91 VENT LINESLOPE 18" PER FOOT MIN. TO TANKSSTOREELECTRICAL TIE INFIRE HYDRANTE STOPTLSHAGEMAN RDCOFFEE RD30K SPLIT TANKLEGENDVACUUM SENSOR KIT # 1- 87 TURBINEZONE 187BRUGGPRODUCTZONE 287VAPOR LINEZONE 387VENT LINEVACUUM SENSOR KIT # 2- 91 TURBINEZONE 491BRUGGPRODUCTZONE 591VENT LINEVACUUM SENSOR KIT # 3- DIESEL TURBINEZONE 6DIESELBRUGGPRODUCTZONE 7DIESELVENT LINEVEEDER ROOT SENSOR,PROBES,LEAK DETECTORS4 DISPENSER +UDCUDC 1,2,3,4330020-536HYDROSTATICDISPENSER PANSENSOR2 ANNULARS30K SPLIT + 20K330020-536HYDROSTATICDISPENSER PANSENSOR794380-303BRINE SENSOR3 TURBINESUMPS87 , 91, DIESELPRODUCTS330020-536HYDROSTATICDISPENSER PANSENSOR330020-480VACUUMSENSOR116-057-5 LINELEAK DETECTOR3 FILL SUMPS87,91,DIESEL330020-536HYDROSTATICDISPENSER PANSENSOR1 VENT SUMPHEALY TANK330020-536HYDROSTATICDISPENSER PANSENSOR3 TANK PROBES87,91,DIESEL846390-110 MAGPROBE 3 LEAKDETECTORS87,91,DIESEL99LD-2000 VMILINE LEAKDETECTOR6" X 7 FOOT BOLLARDSHB PROPANETANKSITE MAP= Penetrations BRAVO F-75-PE-BRG-D (65) FOR PRODUCT= Penetrations BRAVO F-32-TS-D BRAVO FB (51) FOR VAPOR/VENTNORTHZONE# 6- DIESELPRICE SIGNAIR /WATERSITE HAZMAT INVENTORYCARBON DIOXIDE LIQUIDABSORBANT PADSCIM-TEK FILTERSLIQUEFIED PETROLEUM GAS (LPG)GASOLINE ALL GRADESDIESEL FUEL NO. 2CO2CO2FIRE SUPRESSIONCIRCUIT BREAKERWATER METER SHUTOFFOVER FILL ALARMCIM-TEKFILTERSOUTSIDEABSORBANT PADSOUTSIDE
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.
PEI/RP1200 -17
6.1 General. Spill buckets and containment sumps for tank systems are neither intended nor designed for the storage of petroleum products, but rather to contain small leaks and spills for short periods of time. This section describes the
procedures used to test the integrity of spill buckets and containment sumps to ensure that they do not leak.
6.2 Spill Bucket Integrity Testing — Hydrostatic Test Method.
WARNING: Do not use fuels such as gaso- line, E85 or diesel as a test fluid because they present a serious
fire and safety hazard. Gasoline vapors are flammable and can explode if exposed to an ignition source such
as a spark or open flame. If a tank or containment area is not tight, using fuel as the test fluid will cause a
release into the soil or groundwater.
6.2.1 Purpose. This method is used to test the integrity of single-walled spill buckets or the pri- mary containment of secondarily contained spill buckets.
FIGURE 6-1. The hydrostatic method of determining spill bucket integrity uses water to detect leaks. The measuring stick
must be placed in the same location at the beginning and end of the test period to ensure accurate water level readings.
6.2.2 Description of Test. The spill bucket is filled with water. The water level is measured at the beginning and end of the
test.
6.2.3 Test Equipment. Test equipment shall include:
• water;
• measuring stick that is accurate to within 1/16 (0.063) inch and of sufficient length;
• plumber’s plug (appropriate size, if used);
• stopwatch or other time-measurement device capable of measuring a 1-second increment.
6.2.4 Preparation.
1. Care should be taken when conducting the test in the rain or during freezing weather condi- tions.
2. Remove and properly dispose of any liquid and debris (leaves, sediment and trash) in the spill bucket. Clean the spill bucket and examine it for damage, defects or improperly installed compo- nents. If there are loose components (e.g., loose band
clamps or bolts), tighten these items before conducting the integrity test. If there are items that must be repaired or replaced
(e.g., deterio- rated gaskets/seals or drain valves), notify the owner/operator.
6. SPILL BUCKET AND CONTAINMENT SUMP TESTING
Water Level
3. Examine the fill cap and adapter fitting for loose, missing or damaged parts, and make necessary repairs. Complete any repairs before putting water in the spill bucket. Make sure that the seal on the fill cap is present and in good condition. The cap must fit securely and be leak- tight on the riser. The water level during the test typically will be above the cap, so a leaking cap will result in a failed test. As an alternative to a tight-fill cap, use a plumber’s plug in the fill riser if approved by the authority having juris- diction (AHJ) and tank owner.
4. The spill bucket drain valve, if present, must be leak-tight to pass the test. If it is not leak- tight, it may be possible
to simply remove and permanently plug the drain valve. However, if you choose to permanently plug, ensure that the local regulations allow this modification.
5. If the spill bucket is found to have cracks, loose parts or separation of the bucket from the fill pipe, it is not considered to
be liquid-tight. This visually indicates a test failure.
pei.org
Recommended Practices for the Testing and Verification of Spill, Overfill, Leak Detection and Secondary Containment Equipment at
UST Facilities
NOTE: If the fill cap is not included in the spill bucket test and/or the cap is not tight, it could be the source of
potential fuel contami- nation from water intrusion.
NOTE: Before permanently plugging, ensure that local regulations allow the drain valve to be permanently plugged.
6.2.5 Test Procedure.
1. Add water to the spill bucket to a level within
1.5 inches of the top of the spill bucket. Allow the water to settle for 5 minutes before the initial water level
measurement is taken.
2. Place the measuring stick vertically at the lowest point in the spill bucket and extending above the water level to allow
for an accurate measure- ment to be taken. The location of the measuring stick must remain the same for each water
level measurement. Document the initial water level measurement as measured from the bottom of the spill
bucket. Alternative measurement meth- ods may be used provided that measurement to 1/16 (0.063) inch can be
made.
3. Take all precautions to prevent the water level from being disturbed during the duration of the test.
4. After 1 hour, document the ending water level measurement.
5. Upon completion of the test, remove and dis- pose of the water according to Section 6.7, and dry the inside of the spill bucket before returning it to service.
6.2.6 Pass/Fail Criteria. If the water level has dropped less than 1/8 (0.125) inch, the spill bucket passes the integrity test.
If the water level has dropped 1/8 (0.125) inch or greater, the spill bucket fails the integrity test.
6.3 Spill Bucket Integrity Testing — Vacuum Test Method.
6.3.1 Purpose. This method is used to test the
the spill bucket. The vacuum level is monitored for a 1-minute period.
6.3.3 Test Equipment. Test equipment shall include:
6. SPILL BUCKET AND CONTAINMENT SUMP TESTING
14
• vacuum test apparatus (The test apparatus may be available from the spill bucket manufacturer. It includes an air pressure regulator, a vacuum source, a vacuum gauge with a minimum 0-50 inch water column range and a control valve. The control valve is used to adjust the vacuum level.);
• test cover (The cover is equipped with a test fit- ting.);
• plumber’s plug (appropriate size, if used);
• stopwatch or other time-measurement device capable of measuring a 1-second increment;
• gasketing material (The purpose of the gas- keting material is to provide an air-tight seal between the test cover and the spill bucket.).
FIGURE 6-2. The cover must make a tight seal with the spill bucket to prevent leakage when the vacuum is pulled during the
test.
integrity of single-walled spill buckets or the pri-
mary containment of secondarily contained spill buckets.
6.3.2 Description of Test. Using a specially equipped test cover, a partial vacuum is applied to
WARNING: Use only an air-operated vac- uum source or a vacuum pump pow- ered by an explosion-proof motor. Vacuum
pumps with electric motors that are not
pei.or
Plumber’s Plug in
Tank Riser Pipe
Control
Valve
0 - 50" Water Column
Vacuum Gauge Vacuum
Source
g 15
EMERGENCY STOP (ESO) SWITCH OPERATION INSPECTION
Facility Name:Name:
Address:ICC Certification #:
City, State, Zip Code:Expiration Date:
LAFD Facility I.D. #:Company Name:
This procedure is to verify the operation of all emergency stop switches/buttons (E-stops). Each E-stop must disconnect power to dis-
pensers, submersible turbine pumps (STPs) and all non-intrinsically safe electrical equipment in classified areas. Test each E-stop
sepa-rately. See PEI/RP1200 Section 11 for the inspection procedure. Explain any failure in the comment section below.
E-stop Number or ID
Location
1.E-stops labeled (EMERGENCY
FUEL SHUTOFF) Yes No Yes No Yes No Yes No Yes No Yes No
2.ESO located 20-100 feet from fuel
dispensers and 42-48 inch off the ground Yes No Yes No Yes No Yes No Yes No Yes No
3.After activating E-stop, power disconnected from:
3a. All dispensing devices
on all islands? Yes No Yes No Yes No Yes No Yes No Yes No
3b. All STPs for all fuel
grades? Yes No Yes No Yes No Yes No Yes No Yes No
3c. All power, control and
signal circuits associat-
ed with the dispensing
devices and the STPs?
Yes No Yes No Yes No Yes No Yes No Yes No
3d. All other non-intrin-
sically safe electrical
equipment in classified
areas surrounding fuel
dispensing devices?
Yes No Yes No Yes No Yes No Yes No Yes No
4.Area around ESO remains
free of obstructions? Yes No Yes No Yes No Yes No Yes No Yes No
5.After testing, E-stop has
been reset and power rees-
tablished to normal operat-
ing condition?
Yes No Yes No Yes No Yes No Yes No Yes No
Any NO answer indicate a failure of the ESO test and must be explained in the comment section below.
Test Results Pass Fail Pass Fail Pass Fail Pass Fail Pass Fail Pass Fail
Comments:
Tester’s Name (print) ___________________________________ Tester’s Signature__________________________________
Latest Version 4/5/2022
Reference PEI/RP1200-19 Appendix C-11
Person Conducting TestUST Facility
ANNUAL SHEAR VALVE
TESTING ➢This form may be utilized to document testing of shear valves (a.k.a. impact, crash, safety or fire valves).
➢Testing of all shear valves is required at least once every 12 months per Date of Test
UST Facility Person Conducting Test
Facility Name LAFD Facility ID #Tester’s Name
Physical Address Company
City County State
CA
ICC Certification #Expiration Date
UST Owner Tester’s Signature
Shear Valve Test Procedure
1.Visually inspect the shear valve for proper installation and anchoring. The portion of the shear valve located below the
shear section must be rigidly anchored to the dispenser box frame or the concrete dispenser island.
2.Manually trip the shear valve lever arm. The lever arm must move freely into the tripped position without the use of force
to do so. Lever arm must quickly snap shut the poppet valve.
3.Energize the pump and attempt to dispense fuel from the corresponding nozzle into a suitable container.
4.The shear valve must effectively interrupt the flow of fuel so that no fuel is dispensed from the nozzle.
5.Return the nozzle to the hanging position. Return the lever arm to its proper open position.
Test Data
Shear Valve ID
Dispenser #
Product
Anchored Properly? Y / N Y / N Y / N Y / N Y / N Y / N Y / N Y / N Y / N Y / N
Lever arm moves freely? Y / N Y / N Y / N Y / N Y / N Y / N Y / N Y / N Y / N Y / N
Lever arm quickly snaps shut the
poppet valve? Y / N Y / N Y / N Y / N Y / N Y / N Y / N Y / N Y / N Y / N
Can product be dispensed when
valve is closed? Y / N Y / N Y / N Y / N Y / N Y / N Y / N Y / N Y / N Y / N
Pass or Fail P / F P / F P / F P / F P / F P / F P / F P / F P / F P / F
Shear Valve ID
Dispenser #
Product
Anchored Properly? Y / N Y / N Y / N Y / N Y / N Y / N Y / N Y / N Y / N Y / N
Lever arm moves freely? Y / N Y / N Y / N Y / N Y / N Y / N Y / N Y / N Y / N Y / N
Lever arm quickly snaps shut the
poppet valve? Y / N Y / N Y / N Y / N Y / N Y / N Y / N Y / N Y / N Y / N
Can product be dispensed when
valve is closed? Y / N Y / N Y / N Y / N Y / N Y / N Y / N Y / N Y / N Y / N
Pass or Fail P / F P / F P / F P / F P / F P / F P / F P / F P / F P / F
Shear Valve ID
Dispenser #
Product
Anchored Properly? Y / N Y / N Y / N Y / N Y / N Y / N Y / N Y / N Y / N Y / N
Lever arm moves freely? Y / N Y / N Y / N Y / N Y / N Y / N Y / N Y / N Y / N Y / N
Lever arm quickly snaps shut the
poppet valve? Y / N Y / N Y / N Y / N Y / N Y / N Y / N Y / N Y / N Y / N
Can product be dispensed when
valve is closed? Y / N Y / N Y / N Y / N Y / N Y / N Y / N Y / N Y / N Y / N
Pass or Fail P / F P / F P / F P / F P / F P / F P / F P / F P / F P / F
Comments:
3/2022