Cal. Code Regs. Tit. 23, div. 3, ch. 16, app VI

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Current through Register 2024 Notice Reg. No. 43, October 25, 2024

Appendix VI - Underground Storage Tank Monitoring System Certification Form

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*
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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*
___________________________	___________________________	___________________________	[]	[]
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___________________________	___________________________	___________________________	[]	[]

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*
___________________________	___________________________	___________________________	[]	[]
___________________________	___________________________	___________________________	[]	[]
___________________________	___________________________	___________________________	[]	[]
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___________________________	___________________________	___________________________	[]	[]

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.

Cal. Code Regs. Tit. 23, div. 3, ch. 16, app VI

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.