Bldg. 128, LB15 - Monitoring Certification & Spill Container Test Form.pdf

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

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

10485634 01/08/2025

VA Hospital Long Beach Health Care System - Bldg 128 (LB-15)

5901 E 7th St Long Beach 90822

Tait Environmental Services, Inc 714-434-9995

1431 E St Andrew Pl, Santa Ana, CA 92705

Carlos Peraza

588098

8888686 05/07/2026

Veeder Root # B46762 06/30/2025

01/08/2025 14

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

Veeder-Root TLS-350 Plus 331.00

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

L-1 794390-420 LB-15 Annular ✔

L-2 794380-205 LB-15 Piping Sump ✔

L-3 794380-208 LB-15 Fill Sump ✔

L-4 794380-205 LB-15 Remote Fill Sump ✔

V-1 794380-700 LB-15 Monitoring Well ✔

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.

Check this box if NO tank gauging equipment is installed.

(Do not complete this section if either box is checked.)

Yes No NA

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.

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Test Procedures Utilized for UST Testing

To Whom it may concern:

In cases where manufacturer instructions are not available, Tait Environmental Services, Inc. will utilize industry standard procedures for testing Underground Storage Tanks. The sump manufacturer, Bravo Inc, has test instructions available, however, they also refer to PEI/RP-1200. Test procedures are listed below:

1. Secondary Containment Testing

a. Tank Secondary Containment Integrity (Annular Space) – performed per

PEI/RP 1200-19, Section 4.2

b. Piping Secondary Containment Integrity – performed per PEI/RP 1200-19, Section 5.3

c. Containment Sump & UDC Testing– performed per PEP/RP 1200-19, Section 6.6 (NOTE: Tait Environmental Services utilizes the Incon hydrostatic test equipment)

2. Overfill Prevention Inspections

a. Overfill Valve (Flapper) – performed per PEI/RP 1200-19, Section 7.1

b. Vent Flow Restrictor (Ball Float) – performed per PEI/RP 1200-19, Section

7.2

c. Overfill Alarm (A/V) – performed per PEI/RP 1200-19, Section 7.3

3. Other Testing

a. Spill Bucket

i. Contained in Sump – performed per PEI/RP 1200-19, Section 6.2

ii. Direct Bury – performed per PEI/RP 1200-19, Section 6.6

b. Line Leak Detection

i. MLLD – performed per PEI/RP 1200-19, Section 9.1

ii. ELDD – performed per PEI/RP 1200-19, Section 9.2

c. Electronic Monitoring System

i. ATG Functionality Test – performed per PEI/RP 1200-19, Section

8.2

ii. Sensor Functionality Test – performed per PEI/RP 1200-19, Section

8.3

Please contact our office with any questions regarding these procedures.