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Home My WebLink AboutUNDERGROUND TANK / ,v ~~ F' l "''¡- MONITORING SYSTEM CERTIFICATION For Use By All Jurisdictions Within the State of California Authority Cited: Chapter 6.7, Health and Safety Code; Chapter 16, Division 3, Title 23, California Code of Regulations This fonn must be used to docwnent testing and servicing of monitoring equipment. A separate certification or report must be prepared for each monitoring system control panel by the technician who perfonns the work. A copy of this fonn must be provided to the tank system owner/operator. The owner/operator must submit a copy of this fonn to the local agency regulating UST systems within 30 days of test date. A. . General Information ---"~ 1_ "" FaclhtyName: ~kc.~ ;;¡;¡ lO'Zh::) Site Address: ---Y Z ~ 1:.tJ \I e:". Facility Contact Person: k\~~~ MakeIModel of Monitoring System: ~ l::é rt B. Inventory of Equipment Tested/Certified Check the a ro riate boxes to indicate s ecific e ui ment ins ectedlserviced: Bldg. No.: City: "'ß.A.\(.E:r.~~ Zip: Contact Phone No.: (..,\~ ) lo.,o S'3"Z.\ -rt.s ~SO D~;~of~esting/Servicing: ~ll.!~ Tank ID: :td.. Tank ID: ~~ o In-Tank: Gauging Probe. Model: 0 In-Tank: Gauging Probe. Model: ~ Annular Space or Vault Sensor. MMooddeell::i' LJ~S.'ðo .- ~ð-'-- ~ Annular Space or Vault Sensor. Model: ----,c::rq3Qð ..c:fDOf ¡¡(Piping Sump 1 Trench Sensor(s). ---=t9 ~ I!fPiping Sump 1 Trench Sensor(s). Model: ~'S'éÞ -'ŽD& lit Fill Sump Sensor(s). Model:~· Q> GVFill Sump Sensor(s). Model: 1<\ "\~9ð - ZooS o Mechanical Line Leak Detector. Model: 0 Mechanical Line Leak Detector, Model: Ill' Electronic Line Leak Detector. Model: æ~~ '-\." . ()Q , 0 Electronic Line Leak Detector. Model: o Tank Overfill 1 High-Level Sensor. Model: 0 Tank: Overfill 1 Hig¡.-Level Sensor. Model: o Other (s eci e ui ment e and model in Section E on Pa e 2). 0 Other s eci e ui ment e and model in Section E on Page 2 . Tank ID: " Tank ID: $T o In- Tank: Gauging Probe. Model: 0 In- Tank Gauging Probe. Model: IJI'" Annular Space or Vault Sensor. Model' m.m. l/iJF ~ Annular Space or Vault Sensor. Model: I~~<to - c.lflf [if Piping Sump 1 Trench Sensor(s). Model; ~.3 eo· to [JVt>iping Sump 1 Trench Sensor(s). Model: _,'iQ.. ~ ~Fill Sump Sensor(s). Model: ~Fill Sump Sensor(s). Model: "580 -'26" o Mechanical Line Leak Detector. Model: 0 Mechanical Line Leak Detector. Model: o Electronic Line Leak Detector. Model: rr'Electronic Line Leak Detector. Model: O'ð~~~'aO . 001 o Tank Overfill 1 High-Level Sensor. Model: 0 Tank: Overfill 1 High-Level Sensor. Model: o Other s eci e ui ment e and model in Section E on Pa e 2 . 0 Other (s eci e ui ment e and model in Section E on P e 2 . Dispenser ID: M \ . '2,.. Dispenser ID: , · e I3l'Dispenser Containment Sensor(s). Model: "'2.08 9"Dispenser Containment Sensor(s). Model: ""2.08 !f Shear Valve(s). I3"'Shear Valve(s). o Dis enser Containment Float s) and Chain(s). 0 Dis enser Containment Float(s and Chain(s . Di~enser ID:.. Dispenser ID: '\ .. \0 Ql"Ùispenser Containment Sensor(s). Model: ~Dispenser ContainmentSensor(s). Model: GO~ r:J'Shear Valve(s). C!"'Shear Valve(s). o Dis enser Containment Float s and Chain s). 0 Dis enser Containment Float(s and Chain s . Dispenser ID:. Dispenser ID: \ \ . \'1"... s"Dispenser Containment Sensor(s). Model: 7-a I5irDispenser Containment Sensor(s). Model: "lO'ò fit Shear Valve(s). Gr"Shear Valve(s). DDis enser Containment Float(s and Chain(s). 0 Dis enser Containment Float s and Chain s . *Ifthe facility contains more tanks or dispensers, copy this form. Include information for every tank and dispenser at the facility. C. Certification - I certify that the equipment identified in this document was inspected/serviced in accordance with the manufacturers' guidelines, Attached to this Certification is information (e.g. manufacturers' checklists) necessary to verify that this information is correct and a Plot Plan showing the layout of monitoring equipment. For any equipment capable of generating such reports, I have also attached a copy ofthe report; (check all that "l!Ply): (J System set-up (J Ala~ history report Technician Name (print): tv\.).~ EU..,~ Signature: l ~GL' Certification No.: 00<0· oS . O~G ( License. No.: Testing Company Name: ~E'U"'''t.'-C EM vr. tþ~ME'~Tk ~". Site Address: ~ZO~ Mt..NCz ~,¡~ , ~KmF-:r.s..~ ~6'3\b Phone No.:{~) ~ -SzÞO Date ofTestinglServicing: II.) /!;lj ft Page 1 of3 03/01 Monitoring System Certification .' .- ;; ,D. Results of Testing/Servicing Software Version Installed: z<f Com lete the Collowin checklist: g Yes (J No* Is the audible alarm 0 erational? Yes (J No* Is the visual alarm 0 erational? Gj(Yes (J No* Were all sensors visuaIl ins ected, functionally tested, and confmned 0 rational? ~Yes (J No* Were all sensors installed at lowest point of secondary containment and positioned so that other equipment will not interfere with their ro er 0 eration? If alarms are relayed to a remote monitoring station, is all communications equipment (e.g, modem) operational? For pressurized piping systems, does the turbine automatically shut,down if the piping secondary containment monitoring system detects a leak, fails to operate, or is electrically disconnected? If yes: which sensors initiate positive shut-down? (Check all that apply) [J Sump/Trench<Sensors; (J Dispenser Containment Sensors. Did you confirm ositive shut-down due to leaks and sensor failure/disconnection? (J Yes; (J No. (J No* For tank systems that utilize the monitoring system as the primary tank overfill warning device (i.e. no rJ N/A mechanical overfill prevention valve is installed), is the overfill warning alarm visible and audible at the tank fill oint(s) and 0 erating ro erl ? If so, at what ercent of tank ca acity does the alarm tri er? % Was any monitoring equipment replaced? If yes, identifY specific sensors, probes, or other equipment replaced and list the manufacturer name and model for all re lacement arts in Section E, below. Was liquid found inside any secondary containment systems designed as dry systems? (Check all that apply) (J Product; (J Water. If es, describe causes in Section E, below. (J No* Was monitorin s stem set-u reviewed to ensure ro er settin s? Attach set u Yes (J No* Is all monitorin e ui ment 0 erational er manufacturer's s ecifications? * In Section E below, describe how and when these deficiencies were or will be corrected. (J Yes (J No* go N/ A (J No* (J N/ A Yes [J Yes (J No No E. Comments: $OFTWAtU: z.. - 'ÍŒ'be:1t. \?~ -= ~ o MSqfèl).. 00 \ "'f\J..'bcs ~ ~ßuJ V~t. 21 Page 2 of3 03/01 ~'" ~ ~ '1 1 F. In-Tank Gauging I SIR Equipment: 1:1 Check this box if tank gauging is used only for inventory control. 1:1 Check this box if no tank gauging or SIR equipment is installed. This section must be completed if in-tank gauging equipment is used to perform leak detection monitoring. Complete the fo OWID2 c ec 1St: 1:1 Yes 1:1 No· Has all input wiring been inspected for proper entry and termination, including testing for ground faults? 1:1 Yes o No· Were all tank gauging probes visually inspected for damage and residue buildup? 1:1 Yes 1:1 No· Was accuracy of system product level readings tested? 1:1 Yes 1:1 No· Was accuracy of system water level readings tested? 1:1 Yes 1:1 No· Were all probes reinstalled properly? -- 1:1 Yes 1:1 No· Were all items on the equipment manufacturer's maintenance checklist completed? II h kl' * In the Section H, below, describe how and when these deficiencies were or will be corrected. G. Line Leak Detectors (LLD): 1:1 Check this box if LLDs are not installed. C It h till h kI' omPle e t e 0 OWIDI! C ec 1St: 121' Yes 1:1 No· For equipment start-up ~r annual equiPme~ertification, was a leak simulated to verifY LLD performance? 1:1 N/ A (Check all that apply) Sunulated leak rate: 3 g.p.h.; 1:1 0.1 g.p.h; 1:1 0.2 g.p.h. I5l Yes 1:1 No· Were all LLDs confirmed operational and accurate within regulatory requirements? !iil Yes 1:1 No· Was the testing apparatus properly calibrated? 1:1 Yes 1:1 No· For mechanical LLDs, does the LLD restrict product flow if it detects a leak? IJit' N/ A ~Yes 1:1 No· For electronic LLDs, does the turbine automatically shut off if the LLD detects a leak? 1:1 N/A r¡ Yes 1:1 No· For electronic LLDs, does the turbine automatically shut off if any portion of the monitoring system is disabled 1:1 N/A or disconnected? !!I Yes 1:1 No· For electronic LLDs, does the turbine automatically shut off if any portion of the monitoring system malfunctions 1:1 N/A or fails a test? a- Yes 1:1 No· For electronic LLDs, have all accessible wiring connections been visually inspected? 1:1 N/ A [jfYes 1:1 No· Were all items on the equipment manufacturer's maintenance checklist completed? * In the Section H, below, describe how and when these deficiencies were or will be corrected. H. Comments: Page 3 of3 03/01 , ; 'to ¡ Monitoring System Certification Site Address: ~ 'ZO b UST Monitoring Site llan ~~ t:.vc ~A('~~æC5:i-J ,:\0$ '$$0: , c::I :~D~~: ~O~ : j ~c:.: : ~~~ . , '1.ðtt , , , , . ... .~.,~,.,.. ..,.J.~.." ~Ds: : : : : : ~O ~ : --- -- Ø!..... ::',8 : . . .~'" . r!.. : : : : ç-x;v;.. $;~M(>: : , ~1t~$C)", ~'ð. ,~P,~. ~:'f~ ~: . p't.i~uù4.~ stM~' , . : : : ~Qq :~P: ~ : ~ : . . . . . .:::,. " '0"" I'"""-t" ~ . '\è. '~t::1 "'--'. . i.J . , . .~ .$~~.~. .A . -z.o9 - Date map was drawn: \ð / Lë /~. 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 identify locations of the following equipment, if installed: monitoring system control panels; 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 for leak detection), In the space provided, note the date this Site Plan was prepared. Page --L of --L- 05/00