HomeMy WebLinkAboutFMC 2013MONITORING 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. J\ 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.
lhe owner/operator must submit a copy of this form to the local agency regulating UST systems within 30 days of test date.
A. General Information
Facility Name: #7773 Fastrip #31 Bldg. No.: -----Site Address: 3501 Mt. Vernon Avenue City: Bakersfield Zip: 93306 ..:.....;...;;...;;..;;....___ __
Facility Contact Person: _0=-.:..:.m.:..:e:..:..r.::;.o....;G:;.;a:;;.:r..::c~ia::..._ ____________ Contact Phone No.: (661) 393-7000
Make/Model of Monitoring System: _V_e_e_d_e_r_R_o_o_t_T_L_S_-3'--5'-0'-----------Date ofTesting/Servicing: 8/612013
B. Inventory of Equipment Tested/Certified
c 'heck the appropriate boxes to indicate specific equipment inspected/serviced:
Tank 10: 12000 Gal. Regular Tank ID: 12000 Gal. Su~er
1811n-Tank Gauging Probe. Model: 847390-107 1811n-Tank Gauging Probe. Modd: 847390-107
181 Annular Space or Vault Sensor. Model: 794390-420 181 Annular Space or Vault Sensor. Model: 794390-420
181 Piping Sump I Trench Sensor(s). Model: 794380-208 181 Piping Sump I Trench Sensor(s). Model: 794380-208
0 Fill Sump Sensor(s). Model: 0 Fill Sump Scnsor(s). Model:
181 Mechanical Line Leak Detector. Model: FX1V 181 Mechanical Line Leak Detector. Model: FX1V
0 Electronic Line Leak Detector. Model: 0 Electronic Line Leak Detector. Model:
181 Tank Ovcrfill/lligh-Lcvel Sensor. Model: 847390-107 181 Tank Ovcrfill/lligh-Levcl Sensor. Model: 847390-107 0 Other (specify equipment type and model in Section Eon Page 2). 0 Other (specify equipment type and model in Section Eon Page 2).
Tank 10: 12000 Gal. Diesel Tank 10:
1811n-Tank Gauging Probe. Model: 847390-107 0 In-Tank Gaugmg Probe. Model:
181 Annular Space or Vault Sensor. Modd: 794390-420 0 Annular Space or Vault Sensor. Model:
181 Piping Sump I Trench Scnsor(s). Model: 794380-208 0 Piping Sump I Trench Sensor(s). Model:
0 Fill Sump Sensor(s). Model: 0 Fill Sump Sensor(s). Model·
181 Mechanical Line Leak Detector. Model: FX1DV 0 Mechanical Line l.cak Detector. Model:
0 Electronic Line Leak Detector. Model: 0 Electronic Line Leak Detector. Model:
181 Tank Overfill / High-Level Sensor. Model: 847390-107 0 Tank Ovcrfill /lligh-Lcvel Sensor. Model:
0 Other (specify equipment t) pe and model in Section Eon Page 2). 0 Other (specify equipment type and model in Section Eon Page 2).
Dispenser JD: 1-2 Dispenser ID: 3-4
181 Dispenser Containment Sensor(s). Model: 794380-208 181 Dispenser Containment Sensor(s). Model: 794380-208
181 Shear Valve(s). 181 Shear Valve(s).
0 Dispenser Containment Float(s) and Chain(s). 0 Dispenser Containment Float(s) and Chain(s).
Dispenser ID: 5-6 Dispenser 10: 7-8
181 Dispenser Containment Scnsor(s). Model: 794380-208 181 Dispenser Containment Scnsor(s). Model: 794380-208
181 Shear Valve(s). 181 Shear Valvc(s).
0 Dispenser Containment Float(s) and Chain(s). 0 Dispenser Containment Float(s) and Chain(s).
Dispenser ID: Transition Sum~ Dispenser 10:
181 Dispenser Containment Scnsor(s). Model: 794380-208 0 Dispenser Containment Sensor(s). Model:
181 Shear Valve(s). 0 Shear Valve(s).
0 Dispenser Containment Float(s) and Chain(s). 0 Dispenser Containment Float(s) and Chain(s).
. . . . •If the factltty contams more tanks or dtspcnscrs. copy thts fonn. Include mfonnauon for ever)' tank and dtspcnser at the facthty .
C. Certification -I certify that the equipment identified in this document was inspected/serviced in accordance with the manufacturers'
guidelines. Attached to this Certification is information (e.g. manufacturers' checklists) necessary to verify that this information is
correct and a Plot Plan showing the layout of monitoring equipment. For any equipment capable of generating such reports, I have also
attached a copy of the report; (check all that apply): ~ System set-up ~ Alarm history report
Technician Name (print): Kristopher Karns
Certification No.: B341 06
Signature: ____ __,~.~-=~~'_/;~...a...::'4.4=-""'"-""'-A-w->,_,,.__ ____ _
=..::~~----------------------------License. No.: .....;;.80.:;..4...:...9::...;0::...;4.:.__ ____________ __
Testing Company Name: Confidence UST Services Inc. Phone No.: (661) 340-8602
Site Address: 3501 Mt. Vernon Avenue, Bakersfield, CA 93306 Date of Testing/Servicing: 8/6/2013
Page 1 of 3
Monitoring System Certification
D. Results of Testing/Servicing
Software Version Installed: 331.01 ~~~---------------------------
c h f II h kr omplete t e o owmg c ec JSt:
1:81 Yes 0 No* Is the audible alarm operational?
1:81 Yes 0 No* Is the visual alarm operational?
1:81 Yes 0 No* Were all sensors visually inspected, functionally tested, and confirmed operational?
1:81 Yes 0 No* Were all sensors installed at lowest point of secondary containment and positioned :;o that other equipment will
not interfere with their proper operation?
0 Yes 0 No* If alarms are relayed to a remote monitoring station, is all communications equipment (e.g., modem)
1:81 N/ A operational?
1:81 Yes 0 No* For pressurized piping systems, does the turbine automatically shut down if the piping secondary containment
0 N/A monitoring system detects a leak, fails to operate, or is electrically disconnected? If yes: which sensors initiate
positive shut-down? (Check all that apply) 1:81 Sump/Trench Sensors; 1:81 Dispenser Containment Sensors.
Did you confirm positive shut-down due to leaks and sensor failure/disconnection? 1:81 Yes; 0 No.
1:81 Yes 0 No* For tank systems that utilize the monitoring system as the primary tank overfill warning device (i.e., no
0 N/A mechanical overfill prevention valve is installed), is the overfill warning alarm visible and audible at the tank
fill point(s) and operating properly? If so, at what percent of tank capacity does the alarm trigger? 90%
1:81 Yes* 0 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 replacement parts in Section E, below.
1:81 Yes* 0 No Was liquid found inside any secondary containment systems designed as dry systems? (Check all that apply)
0 Product; 1:81 Water. If yes, describe causes in Section E, below.
1:81 Yes 0 No* Was monitoring system set-up reviewed to ensure proper settings? Attach set up reports, if applicable
1:81 Yes 0 No* Is all monitoring equipment operational per manufacturer's specifications?
* In Section E below, describe how and when these deficiencies were or will be corrected.
E. Comments: 1/4 gallon of water was removed from the Transition Sump. I also replaced tre Overfill Light Bulb.
Page of 3
Monitoring System Certification
F. In-Tank Gauging I SIR Equipment: [8J Check this box if tank gauging is used only for inventory control.
0 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.
Complete the following checklist:
[8J Yes 0 No* Has all input wiring been inspected for proper entry and termination, including testing for ground faults?
[8J Yes 0 No* Were all tank gauging probes visually inspected for damage and residue buildup?
[8J Yes 0 No* Was accuracy of system product level readings tested?
[8J Yes 0 No* Was accuracy of system water level readings tested?
[8J Yes 0 No* Were all probes reinstalled properly?
[8J Yes 0 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): 0 Check this box if LLDs are not installed.
Complete the following checklist:
[8J Yes 0 No* For equipment start-up or annual equipment certification, was a leak simulated to verify LLD performance?
0 N/A (Check all that apply) Simulated leak rate: 0 3 g.p.h.; 0 0.1 g.p.h ; 0 0.2 g.p.h.
[8J Yes 0 No* Were all LLDs confirmed operational and accurate within regulatory requirements?
[8J Yes 0 No* Was the testing apparatus properly calibrated?
[8J Yes 0 No* For mechanical LLDs, does the LLD restrict product flow if it detects a leak?
0 N/A
0 Yes 0 No* For electronic LLDs, does the turbine automatically shut off if the LLD detects a leak?
[8J N/A
0 Yes 0 No* For electronic LLDs, does the turbine automatically shut off if any portion of the monitoring system is disabled
[8J N/A or disconnected?
0 Yes 0 No* For electronic LLDs, does the turbine automatically shut off if any portion of the monitoring system malfunctions
[8J N/A or fails a test?
0 Yes 0 No* For electronic LLDs, have all accessible wiring connections been visually inspected?
[8J N/A
[8J Yes 0 No* Were all items on the equipment manufacturer's maintenance checklist completed?
* In the Section H, below, descnbe how and when these deficrencres were or wrll be corrected.
H. Comments:
Page 3 of 3
Leak Detector Test Results Sheet
Customer Address: Work Order: 31131
Jaco Hill Test Date: 8/6/2013
Site Address:
#7773 Fastrip #31
P.O. Box 82515
Bakersfield, CA 93380-2515
Site Contact: Omero Garcia
Technician: Kristopher Karns
Phone: 661-393-7000
Phone: 661-340-8602
Product Type LLDType Model Serial No.
Regular UNL Mechanical FX1V
Premium UNL Mechanical FX1V
Diesel Mechanical FX1DV
(Choose One) (Choose One) (Choose One)
(Choose One) (Choose One) (Choose One)
Check
Valve
3501 Mt. Vernon Avenue
Bakersfield, CA 93306
ICC No.: 5264406-UT
Bleed Leak
Off ML. Rate
Holding Tested:
Pressure
15 PSI 20 ML 3gph@
10 psi
17 PSI 23 ML 3gph@
10 psi
15 PSI 18 ML 3gph@
10 psi
3 gph@
10 psi
3 gph@
10 psi
Technician Name:
Signature:
Kristopher Karns, h Technician No.:
-Y' A _ • ... Date: ----+:fV.~.A__._..:...=.......,__o.=..;;...:...'
634106
8/6/2013
Pass/Fail
Pass
Pass
Pass
(Choose One)
(Choose One)
FH-STF: II '/'13
350! I IT \/EF:'ION B~J:ER:::il'l EU1 C~
hU] b . 2013 !2 :~0 PM
S'.'STEtl : >TiiTUS REkO~:T
1-1LL FIIN "T I Or~ NORI·it-11.
I NVEIIfOJ.:'.' REPOET
T l : l,t,l I .. Hl 1F.l'
\ivLUI'IE '1'158 •';t1U;
ULL11GE ·1:-;0..J (;11LS 90'~ ULL!;i;J:. 3097 GALS rc· \/OI.ll111: " 7t.30 GALS
HEIGHT • liS. 09 I NCHI-}i
!.lATER VOL • 0 GAL~,
Wf-1TER 0 . CJO I NCHI ::;
TF.11P 8 j . b [IE(; r
T :' : l• I E:":EI.
VOLUi'lE 2':.!'18 Gi-lLS
lJLL1-1GE ~~~ I -1 GALS
90'. ULLI'I~~C· 7':107 GALS
T(; lfOLUI IF. A 2908 GALS
HEIGHT "' 82. 5•1 I NtH!=:·
Wf,TEP. 'dOL -I) GALS
WI-1TER 0. • ·ll I NCHE:; TE~Ir• 8~. 5 DEG F
T J :I'REt11UII
V<lLUME 3879 GALS
IILLIIGE 0183 G11LS
"!()", IJLl.I-IGE• 697b GALS
TC VO!.UIE .. 3792 GALS tn: I GHT -!3<-t . 73 11'1 ~·HE:"-:
t.IMTEF. VOL I 2 GALS l~HTEh 0. 713 I J.j.~HES
·1 u~r· ·' 1 . 8 I:• EO:; F
SOrTJ,I:,R[ REV I! i I 01'1 LEVEL
IJEF:til 01 1 331 .IJ! S0F71~1REII 3o.lf ~j:JI-1 00-B
•::Rr.:~TF.f• I I . tl ) . 22. It.. 28
S-l'iOI•ULEII 3301 G0-004-a
S'.'STEM FEMTUP.I~:
PCRII'lf!JI' HI TANI: TESTS
Al'lWIHL I N-T;..Nt: TESTS
:f;JI llf-11
SYSTE11 SETUF·
I-lUG E.. ~'013 1~':4U Pl•l
SYSTE11 IJNITS u.s.
SVSTEt1 Lr1NGUAGE
ENGLISH
S\'STEI'I DATE. TJf·lE FORI1t1T
HON [1[) YVYY HH: 1'11: Sf; -.H
FHSTRIP '/'/3
350: 11T \I[RNON
BAKERSFIELD C'A
SHIFT Tlr1E I
SHIFT TII"lE 2
SHIFT Tli·IE 3
:::>HI FT T Jl·lE 4
ill SHAI.EfJ
D!SAH!ED DIS~-tHLED D I SA81.F:Il
T11NK PER ·mT NEEDED 1•1'-'N
DISABLED
TANK ANN T::;T NEEDED WJ.?N
DISABLED
LINE RC-EN11ULE METHOD PASS LINE TEST
L I NE PER T~;T NEEDED WJ\'N DISABLED
LINE AI'IN TST NEED£[, loJRN
ftiSABLED
PP-INT TC VOLLtiES
EI-IABLED
TEI·lP (:0t1!=·EI,!Si-IT I ON
\/AI.UE <DE;:; F > : 60. 0
ST I Gt: HE I ~HT OFFSET
DISABLED
ULLAGE : 90'.
H-PROTOCOL DATh FOR"Ii-IT
HEIGHT
Dr-.VL I GHT Si-IV If¥> T I 11E
[JISflBLED
RE-DIRECT LOCI-II r~R I NT OUT
DISABLED
EURO PROTOCOL PF<EEIX s
S'/STEI'l SECUR I T't
CODE : 000000
111-t l NTENf1NCE HI ~;TOR'/
DISABLED
T14NK CHI-iRT SEGU~ITY DISABLED
C'LSTOM HLhP.i'-18
DIS1-1BI.ED
SERVICE 1-K>T I C'E
DISABLED
I SO 31 bE:. COUNTRY ('ODE :
V1-1YOR MONITOR I Nt:; TYPE CARB IS[J
11ASS DENS IT'/
DISABLED
CO~ldUI·JII 'AT I <)NS SET JP
POH SETT Jl'l•_;s:
IJOMN BOr~R[I : I { EV I M )
RS-232 SECuR lTV
,·ooE : [;ISI-IBLED
COf~f·'l BOHR!) 2 < Rf:: 23:? >
BAUD RI-ITE 960(1
PnRITY NONE
STOP BIT I ST()P
DI-\TA LENGTH: 8 DATA
I<H-232 SECURIT'/
('ODE : DISABLED
l'Om1 BOARD 3 {RS 232>
HAUD RATE 9600
PAR I T'1 NONE
f3TOP BIT : I STOP f;ATii LENGTH: 8 DATA
J<S 232 SEC'UJ<IT'I (;ODE : DISABLED
AI JTO TF.I-INSI1 IT SETT I N.>S :
AUTO LEAl: !-1LAR:·1 Lll"ll T
DISI-1BLED
AUTO HIGH I~TEP. Llt"'IT
or;,,,BLED
AUTO OVERFILL Ll MIT
DISABLE[!
AUTO LOW PRODU('T
DISABLED
AUTO THEFT L I f'l IT
[•I Sf.\ BLED AUTO DELIVERY STHRT
DI~ABLED
AUTO DEi. I V£1.:'1' END
DISABLED AUTO E!~TEP.NI-\L INPUT ON
DISABLED
AUTO E;\TEH:AL INPUT OFr
DilJAI:JLED
AUTO SENSOR FUEL ALARf•l
DISABLED
AUTO SENSOR I.IATER ALAid1
DISI-IALED AUTO fiCNSOR OUT ALARI1
DISAHI ED
kS-2'1? END or l·1ES.'SI¥.>E
DISABLED
l rJ-TANf~ SET I IP
T l :UNLEADED
PRODUCT CODE
THEP.I·!AL COEFF
TMlt: D I Af•1E1TR
T/4Nl: PROF I I.E
FULl. VOL
FL01~T SIZE:
WI-ITER ~·JHRI~ INC~ :
HIGH WHTER L1 111 T:
l
.00(1?00
Ill . c:o
I F•T
I 21Jt.o:2
4 .0 IN.
W1TEP. ALAP.f·t ri LTEP.:
2.0
3.1J
LOW
1-!1-1;< OF: LABEl. VOL;
iiiJERF ILL L HII T
Ill GH J:>RODUCT
Dr:LI \/ERV L II H T
LObi PF:ODUr::T :
LEAl~ riLARI·l l.ll"l IT :
SUDr•EN LOSS L if•! IT:
TI-INf: TILT
PROBE OFFSET
1206?
CHJ~.
lU8'i5
'35~-~
11459
15~·
1800:,
5DU
'3'3
'Yl
0 . 011
0 .00
~;I PHON 11HN I Fl•LDECJ TANKS
Til: NONE
LINE t1Ai'l I FOUJE[J TAf.H:S Til: NONE
Ll~l-\1: 1·11 N PER I 0LlJ C:
Ll:.l-\1' t11 r-1 ANI~U<1L
p;,
120
1 ~~
120
PEI\'IODl\' TEST TVf'E STI-INDAR[J
1-1NNIJAL TEST FA II.
ALAJ./11 [J l SRBLED
F'ER I O[J! (; TE:3T FAIL
I~LI-IJ.:I·l D ISABLE[I
GRO: ;~j TEST Fl-\ I L
1-\U\Rf'l DISABLED
ANI~ TEST F'\VERi-11_; lNG: OFF
PER TEST rWERI-IG I NG : OFF
TANK TEST NOTIFY: OFF
nw T:3T SIPHON BREf.1l::OFF
DEL I VERY DEL!-\\' : 1 t•!l N
;·UMP THRESHOLD : I 0. 00'-.
T 2:DIESEL
J>RODUCT CODE
THERt1AI. COEFF
TAN!-: DIAHETER
TANK P~OFILE
FULL VOL
FL0f4T SIZE :
~JATER WARNING :
HI GH t.JATER LIMIT:
<>
.00045U
Ill .00 IPT
12062
4.0 IN.
WATER ALARI'l F! LTER:
2.0
3.0
LOW
l'lA>< OR I ABEL VOl. :
OVERFILl .. LIMIT
HIGH f.'RODUCT
DELIVER'/ Ll11IT
LOW PRODUCT :
LEAK ALF'\RM LIMIT:
SUDDEN LOSS Ll ~1 IT:
TANK TILT
PROBE oFFSET
12062 9~· 10855 95~·,
11459 15},
1809
500
99 99
0 .00
0.00
SIPHON MAN I FOU•ED H\NKS
Tit: NONE
Ll NE MAN 1 FOLDED Ti-INKS
Til: NONE
LEAK MIN PERIOD!~:
LE1-1K 11 IN ANNUAL
I~~
120
1%
120
PERIODIC TEST TVPE STANDAR[,
ANNUAL TEST Fi-1IL
ALARf1 D I ~:1-1BLED
1-'ERIODIC TEST FAI L ALARM DISi-IBLED
GROSS TEST FAIL ,..;Lf\RI"I [•I :'>I-IBLEL;
HNN TEST AVERAGING: OFF
F•ER TEST AVERAG I NG : OFF
TANK TEST NOTIFV: OFF
1 NK TST 81 PHON BREI-11: :OFF
l;EL I \/ER\' DELAY I M I N
PUI"1P THRESHOLD : I fJ. 00~.
T ::; : J-·REI•! l U1·1
PRODUCT CODE
THERt1AL COEFF
TANK DIAJvlETER
TAN!-: PROFILt
FULL VOL
: 3
:. 000700
Ill .00
I PT
12062
FLOAT SIZE: 4.0 IN .
!IJAT[R WI-\RN I NG :
HIGH Wf~TER Lll"ll T :
WATER liLARM F I L TEF::
HA'< OR LABEL VOL:
OVERFILL Llf11T
HIGH F'RODUCT
DEL I \/EF:\' L I t·tl T
LOt" FRUDUGT : LEAK ?ILr~RM L I tilT:
SUDDEN LOSS L 11•11 T :
TAN!: TILT PROBl: OFFSET
2.0
3.0
LOW
12062
90~•
10855
95%
11459 15•.:;
1809
500 99 99
0.00
0.00
:::·1 F'HOI'I I'IHI'II FULDEL• TANKS
Tli: NvNE Ll NE MANIFOLDED TANf-.!-:
Til: NONE
LEAl: 1·11 N i='ER I O[J I(; : 1 }.
120
LEAl~ 1"11 N AI~Nli~IL I~< 120
PEP. I Oil I 1..~ TEST TYPE ST~-tNU14RD
ANNUf.IL TEST FAIL ALAR!·! [>I SAUl .E[J
PERIODIC TEST H\IL ALARI'l DlSAULED
GR,}SS TtST FAIL ALAI-!t'l D I Si1Bl.EU
!-iNN TEiJT t-lVEI<HG I NG: OFF
r-ER THiT A\IERr-~G I NG: OFF
Ti-INY. TI::C>T 140TlFY: OFF
TNY. TST S I F•HON BP.Ef-11-:: OFF
DEL I \/ER'/ DELl-\\' : I f'\ I N
PUMP THkESHOLD : I 0 . U,, ll:.
LEI'II: TE~n f•JETHOD
TEST ON 01\TE : ALL TANK
Mf\R 22. :~011
STI-1RT TIME : D I :3HBLED
TEST RATE :0 .. ~0 GAL -HP.
DURI-iT I ON : 2 HOUR:::
TST El-iRL V STOJ> :DISABLE[ I
LE1-1K TEST REPOJ.tf FORf•1!-1T
NORI'lAL
L ! : Ul~l 1-H·it,
NORI!i-11 I '/ (:L··): 01 T•
C!;TE(':(il\'.' ; HIIN11Lnl-: ::·1=·1-1• '}:
L 2; l•:.:r HNN
T!-:1-STAT£"' lSlt~e;u;: rr.<.,;Yf 1 C"nTI:)~OI\'/ : NHJIJI AF? ~J:·I-\r·c
I .J : i>NJ. ~IN'·!
Tf.: 1-BT"TF: \S I N•;LE FLOAT>
r nTE<::O~:'.' : ,~NNI JLriF' ::;?NC[
I. 6 :HJL ~;n•
I' I\ I -STHTE i:~ I N• ;[.E FLOHT >
I 'ATEGOE'.' : SH· f-}lfi'lf'
I. 9 :niSI' 1 2
H:I-STfiTI: <SIIl•3l.E FLOriTl
I 'AT EGO I-N : [• I SPl :1'/:'C;F.f.! PAl J
I I O:£"•i::1P 3-~
Tl-.: I -STriT! . .: <;;I NGL l. H. A-IT i ' HTEco~:-. : r• 1 ~:>r·ErJ:-;u: P14N
I. I I : D I Sl-5 t.
H:! -STf,Tf..: <SJ rJ:;LJ-: FLOAT>
l''h TEGOR'l : (J l Sf'Ef..fiEP. h;tl
L I ? : D I f;l-· ? 8
TR I -STIITE iS l1·~3LI-. Fl.Of-\T > •>\TIC:GOI\Y : [1 I ;:;~·EN: :EP F'F1N
1.1 ::TF.'I-IIJ:~ :aiNP
TR l -STHTE I: il t:GLE :-1.01-!T>
c..,·;·~-;wl-:': : P 1 r·I ;·I(; ~;u~11=·
S I : Ut;LEH[•EI"l TI-IN~: 11: I
D l SPf.NSl: r·Kil •I: :
STi-\IJf•IIF:r•
s '-: J.·Rr:tll un
Tt4Nl: 11: 3 9' ;:;t~:N:~:F r·~or •I;:
., 11-li·J[' .~l
OUTPtfr P.f.l.HV SETlt~·
R 1 :UNL
T'!!=T: r ' ··tr C<>NTP.OL ()Urr·trr
THNl: II! 1
I I GU If' S!':~lSOR HLN:";
L • I : F JEL Al.AF:f'l
L -;t: I'IJEI 141.1-!RI•I
L!O:FIJEI i-ILAR11
Ll I : FIIEL ALAR~ I
L 1 2 : Fl JEL F-ILARtl
L I ~1 : FUEL ALARI1
L •I : SENSOE' OUT ALARH
L c: : Sr.t-iSOR OUT r~LARM
L 1•1 ::'iEN:30R OUT HLARI1
L 1 1 :SENSOR OUT 1-\Lf-\RI·l
L1 . ::ciFI'lf:'OF. OUT ..;LARI·1
L I ' :SENSOR OUT HLAR~I L <I :SII1)RT AU~Rr·t
L 9 :SIIORT AL14RI·l
L I 0 :SHORT ALHRI1
1.1 I :SHORT HL,..;Rr1
1.12 :SHORT AL1-1Ril L I 8 :Sf IORT ALI-IJ<!•I
! SD S l TE dLt-1RM;~.
l Sf• GROSS PREt; FA I L
l :3[J DJ:.:GR[I PRES FA l L
I SL> VAPOR LEAJ: FAIL
!SD 1/f-· FRES FhiL
I SfJ \/P STATU~:i rAIL
J,;[J HOSE ALARI~S
I-ILI.: GR\lSS COLLECT Ft~ I L
ALL!DF.GRf> COLLECT FnlL
ALl.: FLOW COLLECT Ff.\1 L
R ::! :r·rJL TVPE:
PUll!=' CONTROL OUTPUT
TI-INl: II: 3
L IOU l (J ! :ENSOR nLMS
L 6: FUU. ALAf<J·l
L 9 : FUFL r4LAf.;l1
I I 0 :FUEL I-\LA"1·1
1.1 I :FUEl. f-ILA I':~ I
L I 2: rUE I. ALAI<I I
Ll3: FUFI. i-ILAF-:1~
L 6 :SEN!>vR OUT HLf-11<11
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SWRCB, January 2006
Spill Bucket Testing Report Form
This form is intended for use by comractors pe1jorming annual testing of UST spill containment structures. The completed form and
printouts from tests (if applicable), should be provided to the facility owner/operator for submillalto tl;e local regulatory agency.
1 FACILITY INFORMATION
Facility Name: #7773 Fastrip #3 I I Date of Testing: 8/6/2013
Facility Address: 3501 Mt. Vernon Avenue , Bakersfield. CA 93306
Facility Contact: Omero Garcia I Phone: 661-393-7000
Date Local Agency Was Notified of Testing: 7/24/2013
Name of Local Agency Inspector (if present during testing): Ernie Medina
2. TESTING CONTRACTOR INFORMATION
Company Name: Confidence UST Services, Inc.
Technician Conducting Test: Kristopher Karns
Credentials 1: 181 CSLB Contractor 181 ICC Service Tech. 181 SWRCB Tank Tester 0 Other (SpecifY)
License Number(s): CSLB #804904 ICC #5264406-UT SWRCB #09-01743
3. SPILL BUCKET TESTING INFORMATION
Test Method Used: 181 Hydrostatic 0 Vacuum 0 Other
Test Equipment Used: Lake Test Equipment Resolution: 0.0625"
Identify Spill Bucket (By Tank 1 Regular 2 Super 3 Diesel 4
Number, Stored Product, etc.)
Bucket Installation Type: 0 Direct Bury 0 Direct Bury 0 Direct Bury 0 Direct Bury
181 Contained in Sump 181 Contained in Sump 181Contained in Sump 0 Contained in Sump
Bucket Diameter: 12.00" 12.00" 12.00"
Bucket Depth: 13.00" 13.00" 13.00"
Wait time between applying 5 min. 5 min. 5 min. vacuum/water and start of test:
Test Start Time (T1): 1:00PM 1:00PM 1:00PM
Initial Reading (R1): 11.50" 11.50" 11.75"
Test End Time (TF): 2:00PM 2:00 PM 2:00PM
Final Reading (RF): 11.50" 11.50" 11.75"
Test Duration (TF-T1): I hour I hour I hour
Change in Reading (RF-R1): 0.00" 0.00" 0.00"
Pass/Fail Threshold or 0.0625" 0.0625'" 0.0625" Criteria:
Test Result: 181 Pass O Fail 181 Pass 0 Fail 181 Pass 0 Fail 0 Pass 0 Fail
Comments-(include information on repairs made prior to testing, and recommended[ollow-upforfailed tests)
CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING
I hereby certify that all tile information contained in this report is true, accurate, ami in full compliance with legal requirements.
Technician's Signature: Date: 8/6/20 13
1 State laws and regulations do not currently require testing to be performed by a qualified contractor. llowever, local requirements
may be more stringent.
SITE PLOT PLAN for:
015.021-003018
#773 MT. VERNON AVE.
BAKERSFIELD, CA 93306
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UNIVERSITY AVE LEGEND
L 1 87 ANNULAR
L2 DSL ANNULAR
L3 91 ANNULAR
L4 87 STP
LS DSLSTP
L6 IU STP
L9 UDC 1·2
L10 UOC 3-4
L11 uoc s-e
L12 UOC7-8
L13 TRANS SUMP
ESO EMERGENCY SHUT-OFF
OFA OVERFILL ALARM
• PRODUCT SPILL CONTAINER
41) VAPOR SPILL CONTAINER
/1;J ANNULAR * FIRE EX11NGUISHER 0 GAS METER SHUT-OFF
• WATE.R METER SHUT-OFF
@ HEALVCAS * EVACUAllON MEEllNG POINT
Job Order /Invoice#: 5 ( ( S (
"BUILD WITH CONFIDENCE" "COMPLIANCE WITH CONFIDENCE"
Lic.970703 Lic.804904
Toll Free #: 1-800-339-9930
Name: Confidence UST Site Name: :llrr-=?5 M.st/2 t p -rT !5 I
Street: 16250 Meacham Road Street: .S.5C> \ ""-"T v~, J...A.JL:::"'.
City: Bakersfield CA 933 14 City: ~~,-b .<:.Ci£U) State: C ~A-..Zip:
Terms: /Y')()f'..) Cfi'>J lM /,.... C'L:.JL_,T Store No:
Descriotion of work performed:
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TRAVEL and LABOR (0.5 Hour Minimum Labor Charge) OVERTIME (5:00 PM -7:00AM)
Date Technician(s) Name Start End Total OT Start OTEnd OTTotal
bB/{/Jf ut\~AJr Travel
Labor 3bM.ttv
Travel
Date Technician(s) Name Start End Total OT Start OTEnd OTTotal
Travel
Labor
Travel
Date Technician(s) Name Start End Total OT Start OTEnd OTTotal
Travel
Labor
Travel
SUPPLIES -MATERIALS -RENTALS Check One
Qty. UST Parts Site Parts
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COMMENTS
Store Employee Date
INVOICE -WHI1 t: SITE -CANARY