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MONITORING SYSTEM CERTIFICATION
., Fol' Use By All J'lirisdiclÎon.s Within the Státe of Californ;a
..·.11111101'11'>' CJ1ed: Ch"pteT 6.7, Heallh(md Safety Code; Chapter ]6.. D;virion J, Title 23. California Code ofRegll/mion.s
~'his foJ'lu \1)1,l.¡¡t b,e u:.Ied to document testing Ulå ser"ic~~ ofmonicoring equipment. A s~pal~tc certification Or report muSf be 9n:pàrcd
lOr ~'I.;;h T\\o1J,ltoCLng system control panel by: the techmclan who performs the work. A copy oftbls form must be provided to the tlillk
:.Iy~n:lll (lw¡),m'OpCnuoT, The owner/opera.tor must submit a copy of this tom1 to tbe local agency regulating UST systems within 30
J¡I~,~ ùf [-:':11 dt\u:,
A. Gt:ß~rallnformation
,hldlhy N~l11è: Yl,m' e,., 4-1- __ /JeI$P lr¡-./1L
Sir~ Address: !::/~~'- 4 Tilt :¡(T
F,)c ¡lil) ContllCt Pel'son: ~}~ '
}"h\!(¢iModl.!l of Monjtoring System: ~~S - CA.Wl;(Jfj
:a. Jnvè.lltory of Equipment Tested/Certified
C:I,<,I:I( rl.., :\ ) ]ro JJ'Ílllè bo~e¡¡ ro icdíCRTt S t,1O~ e III meRllns e~ted/¡¡...r¥;"~( '
_ Bldg. No.:
____ City: ß"'ttJ~SF,F¿O,_~. Zip: '33ð J
Contact Phone No.: ( )
F cr - ~ Date of Testing/Servicing: lfl.J ..1L1¿Þ~
Tanl. W: _...B~ L
o ¡II-Tank Gllu~il\g PI'ob~, Modcl:
\G Annular $pili:è OJ' Vauh Scnsor. Mod!:l: ~_ (lJlfÂITIf1(¡
b Piping Sump I Tl'CDCh Sensor(s), Model: ____ _.
Q f'jlJ Sump Scnjorls), Model:
o r\'kduu1ÏcIII.l..inc L.cak Deleetor, MOd~I:
o n~'1J'(I!li¡; Line ~11k ~ttC[Or. Model:
Ol\mk Ü\'<:I'11U / High-level SenllO!, ModeJ: _._.
CJ ()thèr{~ )cd', 'ui oHmt I' e and model in Section E ool"a'e 2 ,
Tl\ul> lD:
Û 111- .\'11,nK Gaï;'ging .Probe-, Model: __
o AUIlUhll' Sf>l1c~ iJr Vmllt Sensor. Model;
o Piping Sum~) / T1'.::IIC'h S~l1S\)r(s). Model:
o fJlJ :Swnp Sensø1'(!!). Mudel;
o Ì\'l¡;,hilnical Line l.eak Del~cl0r, Model:
(J EI~.:n'L)llic Line Lee.\: Dctcctor. lV!Qdcl: --'---__.__._
Q Tank OVdJ'lìU I High-Level Sl:Jlsor, MOdel:__
Q Ur!!,~I' t;; ~i!'v ~ \I l'\'1çnr! e and modl!J in Section E on J>a e? .
Dis¡JcDser lJ):
o D1~p;:ns.:r COl}[ailUllcnr 5':0501(5). Model;
o ~h'::iI' VuJve{~),
o Dis l~n~ðl' Cl)fi¡¡ljnmr:m FII>::l1 g and Chain s '
,l.)ibpellsúl'lD: _
o Dispenscl' Çun¡ahunent S~n.sor(s). Model;
o Sh~¡u' V¡¡lvc(s).
Q ~)is êlb~I' Conl::iinmellt FillS! ~) Ib'Id Chaín 5 '
Dispell~cr .lo: _ ,'.
ç:¡ l)~'¡I)<!l1s~r CQlltllinl\wnt S&!cnsor(s), Mod~I:__
o Sheai' V al\'o:!ls) ,
CJDi,¡ 1c:'nSc:'r CùnmjllJ'\1t!ß[ Float S OJ'Id Chain s).
'Jfrbc lilcj ÎI)' conriiins more 1¡U1ks Dr dispenser!!, ~Ùpy this fonn.
Tank ID: ~f- __--___
o In·Tank Gauging ?r1)1>e. Model:
~ Annular Space or Vault Sensor, MOdel:~~~__,
o Piping Sump I Trench Set1SOr(s). Model:
Q Fill Sump Sen.~r(5). lvlQdcl:
o Mechanical Line Leak Delcctor. Model:
o Elecuonic Line Leak Detector. Model:
a TáDk O\lertìll/,Hlgh~Level Sensor, Model:
Q Other s eci 'c ui menr t e ~nd model in Seclion.1:: on PI! 'o:! 'J}.
Tank ID;
o In-Tank Glilugin¡ Probe. Model:
o Annular Space or Vault Sensor. Model:
Q Piping SU!TIP I TrenCh Sensor(s). Model:
C Fill S~mp $cnsor(s). Model:
o MechMjç~ll,ínc Leak. Detecror. Model:
o Electronic Lil1ð Leak DC'tCttor. Model:
Q Tonk. Oveltilll High-Level Sensor. Model:
Q Otller s eci c ul mcnt , e and model in Section Eon Pa 0: 2),
...'----
Dispenser ID; _
i:I Di9penser COllUlinrnCnl Sensor(s). Model: ~.
o Shesr Vnlvels),
Q .Dis \'!nsè.r Conn inmenr .Float s and Chain s ,
Dispenser ID; ,
o Dispenser Containment Sellsor(s). Model;
Q Shellf Valve{s).
o Dís nser CO[l,tllinmenr Ploat $ IU1d ChaÎn 5 ,
Dispenser ID;
o Dí£penser Containment Sensor(s). Model:
Q Shear Valve(s).
Q Dis cnser Conl8inment 'F,IOIl 9 and Chain !I .
Include information for every tank nnd dispenser at the facility.
....---.
C. Certít1cation. 1 tllrtify tb. lt the eq"ipOlent ideotU1~d in this dotuòlent was inspected/serviced In accordance with the aUlIBufactllrers'
gúidelllles. Attlu:hed to this Cllrfltšcatíl)u is information (e.g. manul'actureñ' checklists) necessary fo nrif)' that thiJ information is
~orr~L:~ .md a Plot Ph~n ihQwing tbe layc)ü~ ot' RlouitOtiog equipment. For Dny equipmbot capable of generating sueh reports, J have also
"œ,b'" " "PY" tho ".... ("'....It t'" ..pty), 0 ')'$.om ,...up ~~.....
T¡;clmioll!Il Nam~ (priot):....J!.Y4t'V t""IAS(JJ\J Si¡nature: .
Ç~r[iíkatioDNo,: fltJfß"~S"" ij7''T Licel1se.No.: 61/D40- #8..09850
'f ~S[Ü1~ Cùrnpall)' Name: RICH ENV IRONMENT AL Phone No.:~ 61 )~ - 86 a 7
She AddL'\~js: !/.J1)_J!:J..I.Jf ~T fJ+D gp /~ l, (), (;.ø1. 'J.J~ L Dare ofTestlllg1Sçrvicing~ -L!!! !LI ~
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Mollltoring Systtm Certification
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Sof!l\ 'jJ"= Ver~iO.n Ins(alled:
o. R~slJhs of rfestiog/Servic:ing
CÙ1il 'Icl'<:, dh~ folwwinO' checldist;
~ \'~ 0 No'" Is the audible alRrm 0 erationa.l?
a y~.,; ~ 0 No· Is the visual alarm 0 . ra£iOl\(II'?
\;~,; U No* Wel'e all sensors visl.lalJ ins ected, functionall teste IiInd confirn1ed 0 n.l:ional?
jG Y.;:s 0 N¡)* Were all sensors installed at lowest point ofsecond:uy containment and positioned so that other equipment will
nat interfere with their 1'0 )et' 0 eration?
If ahu'ms are relayed to a remote ,monitoring !Jtation, is aU cornmunications equipment (e.,g. modE:m)
operari0114l?
Fat' pressurized piping SY$tems, does the t~lrbine al.lton'atically shut dowu it rhe piping secondary contain!\'l~n(
n,onlroring system deœcts Ð leak, fuils to operate, or is eJeçtrically disconnec:ted? If yes: wh.ich senSOl'j injrit1r~
posÜive Shut-down? (Check all thaI QPply) Q Sump/Trench Sensors; Q Dispenser Containment Sensors,
Did au confirm ., it,lve ghur~down due to leaks and sensor failure/disconnection? 0 Yes' 0 No,
o Nû41 For tank systems that utilize the lnonÍtorÍI1g system. as the primary tank overti() warning. device (i.e. n()
o N/A mecbli11ical overfill pl'cvemion vl1lve i9 mstalled), is the overfill warning alarm visible and audible fl[ me œnk
fill oint(s} al\d Q eratin . )ro I 7 [f so, ar what ercent of tank en ací does the alarm tri . "'I'? lJ.'o
Was any morllroring equipmon.t replaced? [fyes, identify s~ci'fic sensors, probes, £1'1' other equipment r~plac~d
and list the OU1J1L1factuter m\n'¢ and model tòr aJJ re lacemenr am in Secrion E., below.
Was liquid found inside any s.,condary conrWnnlenr systems designed as dry syStems? (Check 01/ that apply) 0
Product' a Water. I( es, describe causes in Section E, below.
}I:I \{~:) 0 No'" Was monitorln s ~Hetn set-u reviewed [0 ensure ro e.r settjn s? Attach set u
y~s a No· Is allmonitorÍ1'J e \.II melll 0 cratiolUll er n],¡il1~facturer's s ciñcations?
'" In S;:ct!OI1 E below, describe how and when these deficieD.cies were 01' will be corrected.
, 0 Yes
o N(1*
,N/A
a NQ·
1lP N/A
UEf' \' ÇS
~'"
L.I y ~;~
.YJ No
o y è~·
ëit No
,f.. Cõilluhmts:
licable
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F. Jo-T'}l1k Gnugiug I SIR Equipment:
t! Check thist box. if tank 8B\.IgioS is ~IB"cI only for inventory control,
o Check this box. if no tank g,augina or SIR equipment is it £~111ed,
Thi:::; S¢~[iO!l L11.Ust be completed if in-tank ga.t¡ging equipment is used to perfom11eak detection monitoring.
Culll ¡;,ll!to! th~ ròllowiol!: checklist:
o '{<!s o NoJ· Ho.s till input wil'ing been inspected for propel' entry and termination, including testing for ground œults? ,..
¡.-.,.", ,-
U )'.;;; 0 No* Were all tank gauging probes visu!llly inspected for damage and residue buildup?
--
o .....·I!S Ü No" Was accuracy of system product level readinp tested?
--=- --.-
CI ).';;-5 (J No· Was accuracy of ¡;Y$tem w!l.tèr lèvel readings tested?
a y",.:! Q NolII Wel:e all probes reinstalled properly?
--'
Ü \',;$ Q No· Were. all Items on the equipment milnufaCt\.lfer' : )'I'IalnænMce c.bec.k!i$t completed'1
=--'" '0-
,.. 111 UI~ st:ccion H, below, describe how ¡"Iud when these deficieodes were or will be corrected.
G, Lin~ Leal{ Detectors (LLD):
gao Check this box ífLLDs are Jot installed.
Cu[nlJl~t(' tb~ (0 OW'"!! checklist:
a Yo;S o No· FOl' equipment start-up 01' ruulUal equipment certification, was a leak simulated to verify LLD perforn'l.!\nce?
o N/A (Cherk all that appl)l) Simulated leak ratc; 03 g.p.h.: a 0.1 g.p,h; 1:1 0.2 ¡,p,h.
o Y~'S a No· Were all LLDs confirmed operational and accurate withìn regulatory requircments?
DYes o No· Was the testing apparar.us properly calibrated?
o Y..:s o No· For mechanical LLDs, does dIe LLD resn-ict ,product flow jf it detects a leak?
a N/A
o Yo;S o No· For eJectronic LLDs, does the turblne automatically shut off if the LLD detects a leak?
\ 0 N/A
o '{~s D No· For elecn-onic LLDs, does tho turbine automatically shut off jf any portion of the monitor~ system is disabkd
o N/A Ot' åisconnected?
-~ Yes (J No· For electronic U.Ds, does th~ tLlrbine automatically shut off if any portion of the monitoring system maltùnctiol1S
u
D N/A 01' fails a test?
0 Yes o Nl~" for elecrronic LLDs, have all accessible wiring cOMections been visuaJly inspected?
o N/A
o Yr:s D No· Were aU items on the equipment manufacturer's maintenance checklist completed?
'\I
;. In cb~ Section H, below, describe how 8Jtd when these d.etic:lenele$ were or will be corrè(:ted.
H. Ü.HUments:
_.___..__.M_...·.··
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---.......
-..---.--.--. ....
...--.........
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_...~--
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Mtl1\ito1"Ïng System Certification
UST lVlonitoring Site Plan
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Date map was drawn: _/1:2/ 1/ / d
Instructions
1i )Üll a]rèi:1dy have a dingram that shows all required informacion, you may include it, rather than this page, with yom'
Monilori.og Sy:.'tem Certification. 01' your site plan, show tl\e general layout of tanks and piping. Clearly identify
h)~;lrio)ns of th~ following equipment. if installed: monitoring system control panels; senSOrs monitoring tAnk amnular
sp~l\:es, sumps, dispenser pans, spill cOl1tainers, 01' other secondary containment areas; mechanical or electronic line !ea.k.
deœ..:tQI'~; and in-mnk .Iiquid level probes (it used for leak detection), In the $pace provided, note the date thi.s Site Pl~J\
\-hlS prep¡ ' 'dd,
Pag.e .....!f.... of ~
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