Appendix VI Underground Storage Tank

Monitoring System Certification Form

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

10040881 05/13/2025

JERRY PETTIS MEMORIAL VETERANS HOSPITAL

11201 BENTON STREET, LOMA LINDA, CA 92357

WESTERN PUMP INC. (619) 239-9988

3235 F STREET, SAN DIEGO, CA 92102

RAUL GONZALEZ

673853

8374555 11/14/2025

VEEDER ROOT - B33995 03/27/2027

05/13/2025 11

Monitoring System Certification Form

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-300 434.01

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

L1 794390-409 TANK1 ANNULAR

L2 794380-208 TANK 1 FILL

L3 794390-409 TANK 2 ANNULAR

L4 794380-208 TANK 2 FILL

L5 794390-409 TANK 3 ANNULAR

L6 794380-208 TANK 3 FILL

L7 794380-208 TRANSITION SUMP

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.

SITE HAD ACTIVE L4 FUEL ALARM, DUE TO RAIN WATER. WATER WAS REMOVED FROM

SUMP AND SUMP IS NOW LIQUID FREE AND ALARM HAS CLEARED.

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.

Appendix VIII

Spill Container Testing Report Form

CERS = California Environmental Reporting System, ID = Identification, ICC = International Code Council

TYPE OF ACTION Installation Repair 12 Month

1. FACILITY INFORMATION

CERS ID Test Date

Facility Name

Facility Address City ZIP Code

2. SERVICE TECHNICIAN INFORMATION

Company Performing the 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. TEST PROCEDURE INFORMATION

Test Procedures Used Components Tested

5. CERTIFICATION BY SERVICE TECHNICIAN CONDUCTING TEST

I hereby certify that each spill container was tested in accordance with California Code of

Regulations, title 23, division 3, chapter 16, section 2637.1; that required supporting documentation is attached; and all information contained herein is accurate. I understand that test procedures shall be made available upon request by the governing authority.

Service Technician Signature Date Total # of Pages

10040881 05/13/2025

JERRY PETTIS MEMORIAL VETERANS HOSPITAL

11201 BENTON STREET, LOMA LINDA, CA 92357

WESTERN PUMP, INC. (619) 239-9988

3235 F STREET, SAN DIEGO, CA 92102

Raul Gonzalez

673853

8374555 11/14/2025

OPW - 116874 02/02/2026

PEI | RP1200 - 1 HOUR LAKE TEST T1: DIESEL, T2: AMBER 363, T3: AMBER

05/13/2025 11

Spill Container Testing Report Form

Additional copies of this page may be attached.

6. SPILL CONTAINER DETAILS

Test Method Developed by Manufacturer Industry Standard Professional Engineer

Test Type Pressure Vacuum Hydrostatic

Tank ID

Spill Container Manufacturer:

Method of Cathodic Protection Nonmetallic

Other

Nonmetallic

Other

Nonmetallic

Other

Nonmetallic

Other

Is the spill container minimum capacity five gallons excluding riser volume?

Yes

No*

Yes

No*

Yes

No*

Yes

No*

Method to keep spill container empty

Drain

Pump

Other

Drain

Pump

Other

Drain

Pump

Other

Drain

Pump

Other

Spill Container Test Results Pass

Fail

Pass

Fail

Pass

Fail

Pass

Fail

Tank ID

Spill Container Manufacturer:

Method of Cathodic Protection Nonmetallic

Other

Nonmetallic

Other

Nonmetallic

Other

Nonmetallic

Other

Is the spill container minimum capacity five gallons excluding riser volume?

Yes

No*

Yes

No*

Yes

No*

Yes

No*

Method to keep spill container empty

Drain

Pump

Other

Drain

Pump

Other

Drain

Pump

Other

Drain

Pump

Other

Spill Container Test Results Pass

Fail

Pass

Fail

Pass

Fail

Pass

Fail

8. COMMENTS

Describe all answers marked “Other,” “No,” or “Fail” and each proposed remedy.

* Mark here if:

Spill containers do not have a minimum capacity of five gallons and require replacement.

-T1-

OPW

-T2- -T3-

OPW OPW

TEST WATER LEFT WITH SITE FOR DISPOSAL.