California Code of Regulations › Title 23 - Waters › Division 3 - State Water Resources Control Board and Regional Water Quality Control Boards › Chapter 16 - Underground Tank Regulations › Appendix VI - Underground Storage Tank Monitoring System Certification Form

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
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
___________________________
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
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.
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
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
8. IN-TANK GAUGING TESTING
[] Check this box if tank gauging is used only
						  for inventory
						  control.
Yes
No
NA
[] Check this box if NO tank gauging equipment is
						  installed.
(Do not complete this section if either box is
						  checked.)
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.
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.
1. New
				  Appendix VI filed 5-14-2001; operative 5-14-2001 pursuant to Government Code
				  section
				  11343.4
				  (Register 2001, No. 20). For prior history, see Register 94, No.
				  14.
2. Amendment filed 12-18-2007; operative 1-17-2008 (Register
				  2007, No. 51).
3. Repealer and new Appendix VI filed 8-27-2018;
				  operative 10-1-2018 (Register 2018, No. 35).
4. Repealer and new
				  appendix filed 8-27-2020; operative 10-1-2020 (Register 2020, No. 35). Filing
				  deadline specified in Government Code section
				  11349.3(a)
				  extended 60 days pursuant to Executive Order N-40-20 and an additional 60 days
				  pursuant to Executive Order N-66-20.