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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 form must be used to document testing and servicing of monitoring equipment. A separate certification or report must be prepared
for each monitoring system control panel by the technician who performs the work. A copy of this form must be provided to the tank
system owner/operator. The owner/operator must submit a copy of this form to the local agency regulating UST systems within 30
days of test date.
A. General
Facility Name:
2~' /~jal p
Site Address: '7' c~~O UYi ~J ~ /4l~ amity: _ / k~g~/1
Facility Contact Person: c~~</~ s~.~ Contact Phone No.:
Bldg. No.:
- Zip: 3.3
~ a?2 E1-/_~.z ~
MakeJModel of Monitoring System: //l~. ~ ~ ~ Date of Testing/Servicing: Z /~~t7 ~
B. Inventory of Equipment Tested/CertiSed
Check the HDUroDriatp hnrPC to in(lirata cnar:i:r nn..;.....o..t :..~..o...e.t/ ..e:,.-a.
Tank ID: ~'" [~a;LE90~ ~ - - -- ---- """ Tank ID:
(~In-Tank Gauging Probe.
O~Annulaz S
ace or Vault Sen Model:
M
d
l ^ In-Tank Gauging Probe. Model:
p
sor.
O'lsping Sum
/Trench Sensor(s) o
e
:
M
d
l
/ ^ Annular Space or Vault Sensor.
^ Model:
p
. o
e
: Pipin ump J Trench Sensor(s). Model:
^ Fill Sump Sensor(s). Model: ^ Fili S ensor(s). Model:
Mechanical Line Leak Detector. Model: S- ^ Mechani a Leak Detector. Model:
^ Electronic Line Leak Detector. Model: ^ Electronic Lin Detector. Model:
^ Tank Overfill /High-Level Sensor. Model: ^ Tank Overfill / Hr -Level Sensor. Model:
^ Others ui ment and model in Section E on P e 2). ^ Other (s ui t t and model in Section E on P e 2).
Tank ID• Tank ID•
^ In- Gauging Probe. _ Model: ^ In-Tank Gauging Probe. Model:
^ Annular r Vault Sensor. Model: D Annulaz Space or Vault Sensor. Model:
^ Piping Sump / Tren sor(s). Model: ^ Piping Sump /Trench Sensor(s). ei:
^ Fili Sump Sensor(s). Model: ^ Fill Sump Sensor(s). M
^ Mechanical Line Leak Detector. D Mechanical Line Leak Detector. Model:
^ Electronic Line Leak Detector. Model: ^ Electronic Line Leak Detector. Modes:
^ Tank Overfill /High-Level Sensor. Model: ^ Tank Overfill /High-Level Sensor. Model:
^ Other (s eci ui ment and model in Section E on Pa a 2). ^ Other (s ui ment and model in Section E on Pa a 2).
Dispenser ID: Dispenser ID:
,41 Dispenser Containment Sensor(s).
Ja'`§heaz Valve(s) Model: ~•Cv ~ ^ nser Containment Sensor(s). Model:
. ^ Sh slue(s).
^ Dis nser Containment Float(s) and Chain(s). ^ Dis n ontainment Float(s) and Chain(s).
Dispenser ID: Dispenser ID:
^ Dispe Containment Sensor(s). Model: ^ Dispenser Con ent Sensor(s). Model:
^ Sheaz Valv ^ Shear Valve(s).
^ Dis ser Con oat(s) and Chain s). ^ Di ser Containnren[ t(s) and Chains .
Dispenser ID: --- - Dispenser ID:
^ Dispenser Containment Sensor(s). ei: ^ Dispenser Containment Sensor(s). odel:
^ Shear Valve(s). ^ Sheaz Valve(s).
^Di5 nser Containment Float s) and Chain(s). ^ Drs nser Containment Float(s) and Chain(s).
,. uc ia~n,~y wnrmns more [anKS or arspensers, copy ims Corm include urfomiation for every tank and dispenser at the facility.
C. CertificatiOII - I certify that the equipment identified in this document was inspected/xrviced in accordance with the ~nufactorers'
guidelines. Attached to this Certification is information (eg. manufacturers' thet:klists) necessary to verify that this information is
correct and a Plot Plan showing the layout of monitoring equipmant. For any equipme bie of generating such reports, I have also
attached a copy of the repo~(check a~i~leat apply): C^}'~stem set-up report
Technician Name (print): yitl /~GY.~t:~QS Signature:
Certification No.: - ~~' `~ ~S --201-10 License. No.: ~ « a9 ley.
Testing Company Name: ~~ l~t>'-'~ ~L~QsU 1[.~S Phone No.:~ 6 f ~ 38'~ ~~Z--
Site Address: 15~~0 cS~B~ ~. ~g-lC.~~/~,.~d, Cam}. Date of Testing/Servicing: ~/~ Qta
y~3<~
Page 1 of 3 03/01
Monitoring System Certification
D. Results di Testing/Servicing
Software Version Installed: / W i ~ ~
C fete the llowi checklist•
es No* Is the audible alarm o erational?
^ No* Is the visual alarm o tional? -
es ^ No* Were all sensors visuall eesed, functionall tested, and confirmed o rational?
Yes ^ No* Were all sensors installed at lowest point of secondary containment and positioned so that other equipment will
not interfere with their ro er o ration?
^ I'es ^~*
Q )f alarms are relayed to a remote monitoring station, is all communications equipment (e.g, modem)
N!A operational?
Yes ^ No* For pressurized piping systems, does the turbine automatically shut down if the piping secondary containment
^ N/A monitoring system detects a leak, fails to ope_rat~e or is electrically disconnected? ff yes: which sensors initiate
ositive shut-d
?
Ch
k
l
p
own
(
ec
a
l that apply) tef. Sump/Trench Sensors; O Dispenser Containment Sensors
.
Did ou confirm sitive shut-down due to leaks and sensor failure/disconnection? QY~es; ^ No
Yes
^ No* .
For tank systems that utilize the monitoring system as the primary tank overfill warning device (i
e
no
^ N1A .
.
mechanical overfill prevention valve is installed), is the overfill warning alarm visible and audible aj~he tank
fill int(s) and o ratio ro rl ? ff so, at what rcent of tank c aci does the alarm tri er? y0 ~
Yes* ^ No 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
^ Yes*
No ,
.
Was liquid found inside any secondary containment systems designed as dry systems? (Check all that apply) ^
Product; ^ Water. If es, describe causes in Section E, below.
es ^ No* Was monitorin s stem set-u reviewed to ensure ro er settin s? Attach set u r rts
if a livable
Yes ^ No* ,
Is all monitorin ui ment o rational er manufacturer's s ifications?
* in Cv~fi nn F hnlnm .7~ ..:a... ~... _~ ~L__
- ------- -- .--..~,., u..a..,,,,~ aavw iauu wueu auese aencaencaeS were or Will be C011'eCted.
E. Comments: __ l ~ ~'!a-Gr l~,A ~ /Nt~ ~-K f~ f~C-1~ OL a l~~/~
Page 2 of 3 03/03
F. In-Tank Gauging /SIR Equipment: ~ eck this box if tank gauging is used only for inventory control.
^ 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.
Co Iete the followin checklist:
Yes ^ No* Has. all input wiring been inspected for proper entry and termination, including testing for ground faults?
Yes ^ No* Were all tank gauging probes visually inspected for damage and residue buildup? .
es ^ No* Was accuracy of system product level readings tested?
es ^ No* Was accuracy of system water level readings tested?
es ^ No* Were all probes reinstalled properly?
Yes ^ 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.
G. Line Leak Detectors (LLD):.
Complete the following checklist:
^ Check this box if LLDs are not installed.
Yes ^ No*
^ N/A For equipment start-up or annual equipment c rtification, was a leak simulated to verify LLD performance?
(Check a!! that apply) Simulated leak rate: ~g.p.h.; ^ 0.1 g.p.h ; ^ 0.2 g.p.h.
e ^ No* Were aII LLDs confirmed operational and accurate within regulatory requirements?
es ^ No* Was the testing apparatus properly calibrated?
Yes ^ No*
^ N/A For mechanical LLDs, does the LLD restrict product flow if it detects a leak?
^ Yes ^ N~*
t~ N/A For electronic LLDs, does the turbine automatically shut off if the LLD detects a leak?
^ Yes ^~Vo*
~[ N/A For electronic LLDs, does the turbine automatically shut off if any portion of the monitoring system is disabled
or disconnected?
^ Yes ^ ~o*
p~N/A For electronic LLDs, does the turbine automatically shut off if any portion of the monitoring system malfunctions
or fails a test?
^ Yes ~^ *
1rl N/A For electronic LLDs, have all accessible wiring connections been visually inspected?
Yes ^ No* Were all items on the equipment manufacturer's maintenance checklist completed?
In the Section 13, below, descnbe how and- when these deficiencies were or will be corrected.
~- ~j
x. Comments- Ic°_~ ,mn 77~ J~s,~ de~~~.s ~~~ .~~ ~s f~e~ ~
__. ~._
Page 3 of 3 o3roi
onitoring System Certification
UST Monitoring Site
Site Address: ~ry~ ~~ ~~1\~ a ~S-/?rte ~s
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::::::::::::::::::::::~ .s: ::.::~:~~ :::::::::::::
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Date map was drawn: ~ ~ «~
Instructions
If you akeady 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 of 05/00
SWRCB, January 2006
Spill Bucket Testing Report Form
This form is intended for use by contractors performing annual testing of UST spill containment structures. The completed form and
printouts from tests (rf applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency.
1. FACII.ITY INFORMATION
Facility Name: BARBER HONDA Date of Testing: 02/15/06
Facility Address: 4500 WIBLE RD, BAKERSFIELD, CA 93313
Facility Contact: STEVE STEEL Phone: 661-834-6632
Date-Local Agency Was Notified of Testing :-
Name of Local Agency Inspector (fpresent during testing:
2. TESTING CONTRACTOR INFORMATION
Company Name: ACE PETROLEUM SERVICES INC
Technician Conducting Test: RON ROGERS
Credentials': LB Contractor y~CC Service Tech. ^ SWRCB Tank Tester ^ Other (Sped)
License Number(s):813616
3. SPILL BUCKET TESTING INFORMATION
Test Method Used: ydrostatic ^ Vacuum ^ Other
Test Equipment Used: Equipment Resolution:
Identify Spill Bucket (By Tank
Number, Stored Product, etc.) 1 UNLEADED 2 3 4
Bucket Installation Type: irect Bury
^ Contained in Sum ^.Duect
^ Contained Sum ^ Direct Bury
^ Contained in Sum ^ Direct Bury
^ Contained in Sum
Bucket Diameter:
Bucket Depth: 12"
Wait time between applying
vacuum/water and start of test:
Test Start Time (T~: 10:00 AM
Initial Reading (R~): 10"
Test End Time (TF): 11:00 AM
Final Reading (RF): 10"
Test Duration (TF - T~: 1 HR
Change in Reading (RF - R~: 0
Pass/Fail Threshold or
Criteria:
Test Result: Pass ^ Fail ^ Pass ^!Fail ^ Pass b Fail ^ Pass ^ Fail
Comments - (include information on repairs made prior to testing', and recommended follow-up for failed tests)
CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING
I hereby certify that all a in u~tron cocontained in this report is true, accurate, and in full compliance with legal requirements.
Technician's
Date: L,~
' State laws and regulations do not currently require testing to be performed by a qualified contractor. However, local requirements
may be more stringent.
SYSTEP9 SETUP
FEB 15, 2GD6 1 I : c^^~ FiM
S'STEM UPl I TS
U.S.
S'ISTEf i LHPdGUtiGE
EtVGL I SH
S'fSTEt°I DRTE,~T I t°IE F~iRMt~T
MON DD ~'': `fY HH : t'9t'i : SS ::t°1
BARBER HONDA
4500 ~J I BLE RD .
BAKERSFIELDrCA
SHIFT TIME I DISABLED
SHIFT TIME 2 DISABLED
SHIFT TIME 3 DISABLED
SHIFT TIME 4 DISABLED
TAN}; PER I Ori I ~~ bJARN I NGS
DISABLED
TANK ANNUAL WARNItVGS
DISABLED
LINE PER I UL'i I ~ : i .};::qjr, IV I NGS
D 1 Sr';BLED
LINE ANNUAL tJr;ktV I NGS
DISABLED: r
PRItVT TC VOLUt'7ES
ENABLED
IN-TANK SETUP
T ! : UPILEt=~DED
PRODUL;'~ CODE -_ 1
THERMAL GOEFF :.D DD6DD
TANK DIAMETEk 92.UD
`'' TA tVK PRf?F I LE I PT
FULL tIOL 5D36
FLtiAT SIZE : 4 . U I t,1. . 8496
WATER 4JARtV I PIy~ ;~ , p
_H I GH WAT1rR L I~t°t I T: 4. D
'MA?S_.OR LABEL VOL: 5036
OVERFILL LIMIT 9D
• 4532
- HIGH PRODUCT. 9g
4784
DELIVERY L I Nt I T I D:~
` 503
LOW PRODUCT 4DD
LEAK ALARM L I P•i I T : 99
SUDDEN LOSJ LIMIT: 99
TANK TILT 0,00
t`7f=tfVIFOLDED TANKS .
Ttt : NONE
TE(1P ~GtNPEtVShTIOIV
-VALUE fDEC; F is 60.Ct
ST I ~ K: HE I t=HT ~sF'FSE'T
DISABLED
H-PROTOCOL DATA FORMAT
HEIGHT
DAYLIGHT . St=tV I tVG T I P•iE
DISABLED•
RE-DIRECT LOC'fiL PRiNTUUT
DISABLED
i
LEAK MIN FER I irD I C : 5
' 251
LEAK MiN r~NNiiHL 5`~
• 251
PERIODIC TEST TYPE
ANtVUAL T-EST FA I L
-AL dSABLED
P~ LC'TEST FA I L
ALARM DISABLED
GROSS TEST ,FAIL
' F;Lr=tRt°I D I SF=,BLED.
ANN TEST F;'v'ERAG I PIG : C•FF
PER TEST r~VERAU I tVG : trFF
LEAK. TEST METHOD
TEST UN DATE ALL TAM:
JAN I. 1996
START TIME DISABLED
TEST RATE :0.20 GALfHk
DURt=iTIt7N 2 HOURS
LEAY. TEST REP:}kT FORMAT
tVC3RMAL
LICVUI,D SENSOR SETUP
L 1 : A[dNULAR
TRi =S'fF,TE t S I Nc3LE FLOAT
CFl'fEGORY r;tVMUL:iR SPhCE
L 2:SUMP
TR I -STATE C S I NGLE .;FLUr=1'I'?
Cfi`£EG~JF.~' . ; ~3T.FiER ' SEPlSfiRS
E:=;TERNHL I AIPUT SETUP
tVOtVE - - - - - - - -
TANK TEST NOTIFY : f?FF OUTPUT RELflS° SETt.~P
TtVK--TST ,SIPHOPJ BREA}~:OFF _ _ _ - - - - - - -
DEL I VEF,''Y L~ELA'r 2 M I N Rti,1 ~ SHIJTDt?Wrd .
TAPE:
ST-^,tdL;ARD
NuRMALLY CLOSED
LI9UI£r,SENJ.Strk ALNi
ALL c T''UEL ALARM
R 2:OVEkFILL
TYPE:
STF;NDARD _-.
NORMALLY UPEIV
I td-TANK ALARt'1S
ALL:OVERFILL ALARt~t
A • e
~LhRt~i HI:~Tt}R~; REP?1R'f
----- t~EFJ:~~+kr;LnFdf1 -----
L t : i=tIVPIULF;R
hi~ltdULHR SPrt~,'E
FUEL hLr~Rt°i
FEB 15. •~'u+J6 11 :31 tit°i
FUEL ~=tL€~RI 1.. _ .
FEE.. Y5 ?~Ub 1 I : ;Ju F+t"Y
SEt~la?k UUT F;L~tRf°l .. '< .
~ - ~ ~ t EI'dC) x ~ ~ ~ x
AL~Rt~I H I STuR~' REF•c}r~T
L, '~ : SUI°iF'
f~THER SEi~tSCiRS
FUEL ~LHRt~
FEB t 5 - ?+~uE i t : au ;;rt
FUEL riLnRll _
FEE i 5 r 2uQra I I• J~J t~M
;;ENSUR i'rUT FiLi-]kt 1 -
SEF 6. 2E05 7 i b r'~M
t x ~ x EhiD ~ ~ '~ " ri
RightFax 9/21/2005 3:56 PAGE 001/002
ABOVEGROUND STORAGE TANKS
APPLICATION FORM A
FOR INSTALLATION /REMOVAL OF AN AST
-/ EM VE
L~ INSTALL C R O
Fax Server
BAKERSFIELD FIRE DEPT.
Prevent3oa Services
900 Truxtun Ave., Ste. 210
Bakersfield, CA 93301
Tel.: (661} 326-3979
Fax: (661) 852-2171
Page 1 of 2
FACILITY
ADDRESS
~Q~
OPERATORS NAM ~ n
C' PERMR TO OPERATE NO.
OWNERS NAM
NUMBER OF TANKS TO BE INSTALLED ~ /REMOVED
,: -
7A1~EK #!O. `: ~ CQNTENT$ .. V4L'UN1E .
~ ~ ~ ~ a~
rJ.' Gi ~,T L~ 64 /I
NAIIAE OF COMPANY INSTALLING 31 OR REMOVING ANK~S) ~
~~~
MAILING ADDRESS //
/ 1 9
NAME 3 PHONE NUMBER OF CONTACT PER ON
. l ~~
DATE 3 TIME TESTIS TO E INSTALLED OR REMOVED
SIGNATURE (CANT DATE ~j
Ap p
~' DATE /~
2 S
~- / f U"LUt31 (Rev. 02/05)
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2331 Driver Road ~ Bakersfield, CA 93312
(661) 588-8090 • Fag (661) 588-8092
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Sales 8~ Service
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9/21/2005 3:56 PAGE 002/002 Fax Server
ABOVEGROUND STORAGE TANK ~:: BAKERSFIELD FIRE DEPT.
°'~ PREVEl'~TION SERVICE8
g"'~"~`'~'~; ! 8 x D 9001Yuxtun Ave., Suite 210
GUIDELINES _ : rl8t Bakersfield, CA 93301
FOR PERMIT TO INSTALL AST ~ ~ Tel.: (661) 326-3979
FOR DISPENSING OF FLAMMABLE OR COMBUSTIBLE t; F`aX; (661) 852-2171
LIQUIDS
Page 2 of 2
GUIDELINES FOR PERMIT TO INSTALL AN AST
FOR DISPENSING OF FLAMMABLE OR COMBUSTIBLE LIQUIDS
A) Any above ground storage tank installed within the City of Bakersfield for the purpose of dispensing motor vehicle
fuels.must meet the requirements of section 5202.3.7 of the California Fire Code, 200'1 Edition and Bakersfield Municipal
Code.
B) The tank sizes shall not exceed a capacity of two thousand (2,000) gallons individual or four thousand (4,000)
gallons aggregate.
C) Any above ground storage of petroleum with a cumulative capacity of more than 1,320 gallon must complete a Spill
Prevention, Control and Countermeasure (SPCC) Plan, per California Health & Safety Code Division 20 Chapter 6.67. A copy
of this plan must be submitted to the Bakersfield Fire Department Office of Prevention Services located at 900 Truxtun
Avenue, Suite 210, Bakersfield, CA 93301 and can be reached at 661 - 328-3979.
APPLICATION PROCESS
Provide twv sets of a plot plan for the facility. This plan must include location of property lines, all buildings and
openings to each building (such as windows, doors, vents, etc.), nearest road or intersection, all tanks piping, any
faed source of ignition (i.e., water heaters, forced air, AC units, etc.), all foundations, and equipment to be
installed.
Construction details of tank pad seismic straps or fixtures, and crash posts.
`7
9
~f~ Applications must be fully completed or they will be returned: no exceptions.
"~ Permit fee must be submitted with the application or the application wilt not be processed.
`~ 9. A final inspection must be completed before AST system is operational. This is to insure compliance with the
UFC regarding placement of placards, and where applicable, the testing of emergency shut-off device, and
~~j~ overfilUoverspill.
Certification by the manufacture that the tank meets the applicable codes.
/)~ 4 Identification of the materials to be stored in the above ground storage tank.
1~ Building permits for all reinforced concrete-and electrical work must be obtained at the Bakersfield City Building
J(, Departrnent located at 1715 Truxtun Avenue, Bakersfield, CA 661- 326-3720. Construction cannot begin
without their approved permit
~~~ Complete any necessary application for the Air Pollutlon Control District for any storage or dispensing of
asoline or aviation fuel.
FD2061 (Rev. 02105)
AUfOMAT1VE
EQUIPMENT
Sales & Service
2331 Driver Road
Bakersfield, CA 93314
Phone: 661-588-8090
Fax: 661-588-8092
www.gwsautomotive.com
Glenn Spence
GENERAL MANAGER
A/C Recovery Equipment
Air Compressors
Air/Lube. Systems
Alignment Equipment
Chief Frame & Measuring Systems
Engine Analyzers
ESP BAR97 Smog Equipment
L~ Above & Inground
7fre Service Equipment