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 A 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.
The 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: Arco AM PM Bldg. No.: ____ _
Site Address: 2698 Mt. Vernon Avenue City: Bakersfield Zip: -'-93_3_0_6 __ _
Facility Contact Person: Monty Hawatmeh Contact Phone No.: (661) 703-7273
Make/Model of Monitoring System: Veeder-Root TLS-350 Date of Testing/Servicing: 8/20/2013
B. Inventory of Equipment Tested/Certified
-----------•• ~ •-• ••••---··--•-·~·-•-n•----·-·---· •••-••• •••---·--·•--• • ·---·
Tank ID: 20000 Gal. Regular TankiD: 12000 Gal. Su~er
181ln-Tank Gauging Probe. Model: 847390-107 [8J In-Tank Gauging Probe. Model: 847390-107
181 Annular Space or Vault Sensor. Model: 794390-409 [8J Annular Space or Vault Sensor. Model: 794390-420
181 Piping Sump I Trench Sensor(s). Model: 794380-208 181 Piping Sump I Trench Scnsor(s). Model: 794380-208
0 Fill Sump Sensor(s). Model: 794380-208 0 Fill Sump Scnsor(s). Model: 794380-208
0 Mechanical Line Leak Detector. Model: 0 Mechanical Line Leak Detector. Model:
[8J Electronic Line Leak Detector. Model: Red Jacket 181 Electronic Line Leak Detector. Model: Red Jacket
181 Tank Overfill I High-Level Sensor. Model: OPW-61-SO [8J Tank Overfill I High-Level Sensor. Model: OPW-61-SO
0 Other (specify equipment type and model in Section E on Page 2). 0 Other (specify equipment type and model in Section Eon Page 2).
Tank 10: Tank 10:
0 In-Tank Gauging Probe. Model: 0 In-Tank Gauging Probe. Model:
0 Annular Space or Vault Sensor. Model: 0 Annular Space or Vault Sensor. Model:
0 Piping Sump I Trench Scnsor(s). Model: 0 Piping Sump I Trench Scnsor(s). Model:
0 Fill Sump Sensor(s). Model: 0 Fill Sump Sensor(s). Model:
0 Mechanical Line Leak Detector. Model: 0 Mechanical Line Leak Detector. Model:
0 Electronic Line Leak Detector. Model: 0 Electronic Line Leak Detector. Model:
0 Tank Overfill I High-Level Sensor. Model: 0 Tank Overfill I High-Level Sensor. Model: 0 Other (specify equipment type and model in Section Eon Page 2). 0 Other (specify equipment type and model in Section Eon Page 2).
Dispenser TD: 1-2 Dispenser ID: 3-4
[8J 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 ID: 7-8
1:8J 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: Dispenser ID:
0 Dispenser Containment Sensor(s). Model: 0 Dispenser Containment Sensor(s). Model: 0 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 facility contains more tanks or dispensers, copy this form. Include information for every tank and dispenser at the facility.
C. Certification -1 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, 1 have also
attached a copy of the report; (check all that apply): [8] System set-up [8] A);lrm history rep or
Technician Name (print): -=B~ryL.:a=.:n:.:....:...A:...S=-e=-l:.:.f _______ _
Certification No.: 837501 --~~--------------
Signature: -u,x,.<~~ 1 y; ~
Testing Company Name: Confidence UST Service, Inc. Phone No.: (800) 339-9930
Site Address: 2698 Mt. Vernon Avenue, Bakersfield, CA 93306 Date ofTesting/Servicing: 8/20/2013
Page 1 of 3
Monitoring System Certification
D. Results of Testing/Servicing
Software Version Installed: 328.03 ~~~---------------------------
c he foil ~--------------~ -kr -,.., ...
[8] Yes 0 No* Is the audible alam1 operational?
[8] Yes 0 No* Is the visual alarm operational?
181 Yes 0 No* Were all sensors visually inspected, functionally tested, and confirmed operational?
[8] Yes 0 No* Were all sensors installed at lowest point of secondary containment and positioned so 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)
181 N/A operational?
[8] Yes 0 No* For pressurized piping systems, does the turbine automatically shut down if the piping secondary containment 1
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) [8] Sumpffrench Sensors; 181 Dispenser Containment Sensors.
Did you confirm positive shut-down due to leaks and sensor failure/disconnection? [8] Yes; 0 No.
[8] 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 oftank capacity does the alarm trigger? 90%
0 Yes* 181 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.
[8] Yes* 0 No Was liquid found inside any secondary containment systems designed as dry systems? (Check all that apply)
[8] Product; 181 Water. lfyes, describe causes in Section E, below.
[8] Yes 0 No* Was monitoring system set-up reviewed to ensure proper settings? Attach set up reports, if applicable
[8] 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: Removed approx. 0.5 gallons of product/water mixture from both STP sumps.
Page 2 of 3
Monitoring System Certification
F. In-Tank Gauging I SIR Equipment: 181 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:
---
181 Yes 0 No* Has all input wiring been inspected for proper entry and termination, including testing for ground faults?
181 Yes 0 No* Were all tank gauging probes visually inspected for damage and residue buildup?
181 Yes 0 No* Was accuracy of system product level readings tested?
181 Yes 0 No* Was accuracy of system water level readings tested?
181 Yes 0 No* Were all probes reinstalled properly?
181 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 LLOs are not installed.
c tete the foil --heckr ........
181 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: 181 3 g.p.h.; 0 0.1 g.p.h ; 0 0.2 g.p.h.
181 Yes 0 No* Were all LLOs confirmed operational and accurate within regulatory requirements?
181 Yes 0 No* Was the testing apparatus properly calibrated?
0 Yes 0 No* For mechanical LLDs, does the LLD restrict product flow if it detects a leak?
181 N/A
181 Yes 0 No* For electronic LLDs, does the turbine automatically shut off if the LLD detects a leak?
0 N/A
181 Yes 0 No* For electronic LLDs, does the turbine automatically shut off if any portion of the monitoring system is disabled
0 N/A or disconnected?
181 Yes 0 No* For electronic LLDs, does the turbine automatically shut off if any portion ofthe monitoring system malfunctions
0 N/A or fai Is a test?
181 Yes 0 No* For electronic LLDs, have all accessible wiring connections been visually inspected? ~ 0 N/A
181 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.
H. Comments:
Page 3 of 3
nPt · aw ~,, ~.:_1• ... ,1:
.;!it18 f'IT ~.lb(li .,, ,., • .-.
f':d\ .. , of lo<·l d
(';.; ~.)~:ut.
~UG :!tl. :~fll :..~ ti: ...t·~ ;-.i •
t:',: :·r H · ~-;,,, i'l.ll:~ u::~·, -~ ·1
nU FlJNCT I' '11;:: tl(lr:IIIIL
r l·l1•t:t·JI'.!F.. RE~·Of''l
'f l : Ul If .EI-\[r[[• r:,•
VvLi 111F · (,.·r.?J (,nt.:::
I.ILI ,;o..L I 023') ,·;Hl S
~1:)• ULLH•}l·;~ ::::::~,·:• •:inLS
TC' III''·I UI'H: -:.<~lOt. I :.-.L:•
H!.l :tH -c:,t: .. t-4 [NI'HE:-:i
l.h.;ll::R \ii>l. = C •3i-1L'
1.-!,..TF.t: " u.2'-l INt. HE~l
TF.I I~ . 85 . ll L•C<:; F
T .:.•: IlL H:IJ II 1'!"1
'<10LU11E
ULLI-IGI:
•)Q' IJLI .i-\o ol:-.
Tt: 1.!0LIJI1E ~
HEI(;HT
1-le;TFj.: \101.
tMfEP. n:nr
:!~I l'l (~Hli.:;
•)G4 2 l;I~I.::::
f34"'7 o:?-;LS
~ 16'-t t:~Ml.S
:.-."•. l 1 I f·ll'HI.·.::; n ,·;r;LS
11. l!U I N•:·Ht:;
84. i I•E(; I'
* ~ •. ,. • Elll' .,. ~ .:: II{ .,.
::;(,1' f't •r~l·T 1\l·.•ll S I :)N I EliLI.
1/D;:) I ·~H~ ·::.:t:. 0~:
:::;(,FTI lli~:1.11 ·:·1!.;1..'tJ· l 00-l!
o''.RI:.Mi£1• iJ~(.Ot .. ilr •. l7 .21
8-lkr)'oUl.l.!l ~;·_HI)~.'.) JJ(J..J "
:.:;'.-: :TU 1 1-'I';.;TIJRLS:
f·E~!i"if 11 II·! T,.,IJl. 'fEST~;
Al1h I. l I I '! ,f II. TE:3T:-·
I:A
-··-· •·' • •..JLJ lJr
AU.,; :~I"J. ~·u i .J 1:J: 'jf) <II I
;::.;•:STFJ ., UN IT~_;
11.:3.
:::;·.-:-:TEn t.;;r~· :u..,,_;r
Ef.l<:r ISH
:·:,::::T.t-:11 [J;..;TL: Tli'IE l''•F:f·~.;r
HON [•!I 'r'.''{'l HH:r~tr:~,}; <1'1
Hf-.1''() arr, ~'" 8:.:'70.3
:?l...;t: ~n \l~·rr'lorr f1v~
P.al ,., => i 1 t? I d,
CH 98'l06
:·;H l FT T If IE
:';HIP!' T I tiE :,
SHIFT 'fi~IE ;)
SHirT TIME ·I
I'MNI: HJ; TST I•!SI-il:ll.E[•
TnrH: nf'JI·I TST
[•I:'H&LEI•
(.; Ou A11
I o!: :nBLEl•
l.r I :"'iHRI £r,
!1ISnE:I ED
Nf.:!':[•Elr J.Jf.; N
HEU•l :Lr l·.ll\rl
I. I NE 1-:'E-EilhBll-. f·U:'I HC.>L• PHS::> LINE TESl
1.1 HE ~-EF: TST I•IEtl I)::J) L·I~:N [J l :'J,,Bl.EI •
L ! NE fWJN TST N!:.TL•~cD t,IJ'<N L<J :JA5l.EI•
F-P.I NT Tl' IIi 'I Ul·l!.:.:: F.NRlJLrD
TEll!·· ,~.)1 lf'En~:;..;T l '-'N
"'f-ILIJE i f•Eo:; F' > : 1·.n .lJ
STI o:·r HE I • ;HT vfTSH frl SAE:l.I:;[J
U!.LMGE: 90'.
H -~·F:OTC• Ol. L•l-t'fii FORI 1~-.T HEI(:Hf
L!fi\'L I•;HT :3AI/ I N•; T I 1·1£ El'ii;HLEL•
START [!,..;TE
t1Rl\' J,JEU: 2
STArn Tll'll:.
2:ou 14'1 ENir [!1-lTE
N0\1 IJEEI~
EN[! ffi"IF
2: no ;.;r·r
SUN
:~uN
P.E-[r IRE( T L•y 'nL !' /..' f l'lT<JIJf L•L:;n8LL:f•
EUR0 ~·k(;'fn,··ot I ·RE.f f. . s
;-:·.:STE11 SJ'('Uf.: I T'f
1. uDE : UOttOUi'l
I'll-\ I l·l'f'F.f<l..,r.I<.'E HI :c:r:,~:·.I• I ~"';1-lE:LfD
J'n111: ''HART ~;f:o 'UP. IT'.' T• I :::t-lfll.El•
(:U!:iW;·I·J HL, ;kl !:-;;;
VI :·~APLE[o
~iFPVll'E lli'1Tl<F.
D I :=:HE> LEI•
f'th::.~s lrlf'l:_; I L'
I• I :3t<lJ!.U•
o_'(,f H 1111~ I Ct;T I i'H·I~, :-::ETlll
Pt1RT .-:lETT I f'lf::
'· ';)1·11·1 H(lHI\[r : I , EC•I f l
RS--2~l::: tii::<:'IIF: IT\
C'OPI: : [I I :':;HUI.L(J
i:Oilf I !:!Prik'l• : • ' ! :-. ·: :,..;1
BnUU R;.;TE : 9&i'JII
r·nR 1 r. : IJJI·Il.:
ST·'•f l~! 'I : l ::iT<>I
[11-\Th LEit•.,;TH: c: flt-11,.;
RS ~32 .~u·r II':! f·,
'. '\[JE : f•l :·;~DLE! I
DTR NURI·fi-',L ~rr~Tt:: H!(;H
,_:i)ll(1 1.:01-\k'[l : :J ( F::~ .::·3::· I
Bnllf• R1-1TE : CJI;)IIU
!•1 IR IT'.' : llvi~E
STOf· 8 IT : I STOf
DI-ITH LEW;TH: :3 [•riTM
R:~: .?32 SE<.'IJP.IT'.·
('i)r!E : D l ::>HF.:I.f-:fr
11UTO TF:HI•J:::r•ll T :3t:T f! N• ::; :
1-1UTO l.l.ht: nL,.,Rr·r L.l!•l I T
I![ f::AUL.E(t
,.;UTC HI ,:;If I'I"TI :R 1.1 r11 T
liiSHDL£[•
f-IUT<) <WEP.l ! LL f ! i'll1
to! SI-IIJi .I::[J
.~uTn L(·l·' H:uc,u• ·r
f•! :::1-18Lf .L
MdTO THEr"r L 1111 r
r11 s .. 8LI::1•
t-~liTC (1LL I 'IER'. ;'sT/-IF:T
[1 I SAil! .ED
AUFl DEL I '.iEP.'; D tl•
[;I :)1-iD!.El•
nUn) t::·(T£::1<!1 /HI I J·tPI.J, <)I I
£• I f'hBLE[•
I\ LITO E. TEf.:i IHL I NPIJ;· ,jfF
C•ISABLED
f-\UTC> SEr,;::;(·f: fUEL ,;Lfll.:1·i
DI~:1-18LH•
f\UT" SEI•i:C:(lF' t.rn ff.i-: 1;LhR! 1
DISHBll::ll
r;IITO :::EI'i:~'J~~ ... 1 rr nl.l ,Ri 1
DISHI:ILE(J
.~
.oo. (1 i . 1]11itl33~il·.:. :fl !(1 i
tl ol.J S .\' '1::11 A!:tnl"l::Ir I
l;{c): :i"3);!d /.1("1! it·.: lS.l. :lt.fJ.
J.:Jo:• :!,.Ill!: •·~"-i:ll,,. !83.:. M3j
.i.l'.l : '.'tl I !)u'::l:ll•.'·' lS3.: N~!'"'
rJ:i"l:-1~--' :fr] (,;-j•,il\-1 ·:I loi.:J .1.:.:31 ::.'SOH~ I
rJ::! l>J••f:I•J .!;·IH"1•'
'1 I '-'J .! S:l I. . • I tiC) I ~J I
• tT 1w•.-: 1 'J ~~-'i' }' f\·1
"11".:1 I :·)3.L 1YitNW'
q;-f!--ltl/1\ il!i
?lei'· L .I ~:?J.I. .) l, lnl'•!:l·i
-.l[.t't:
•• t=.(:
·~r t"r;
·-6< :. J•;c-Ja3-l t·lltJ '1~-""T!
:3!Jf;~ l :Ill
!-.ill\-1.:. •rl'i'10.1!1J1.~.1 Jl-111
31K!J :Ill
!-\;UI'Il rr-JrJ1r\l iiJI-'j.J /!<ill i W
Ml" f) lJS.:I:l'.) ::l':!·)~d
Qt)' fl 11 !l ;(NH_:
"'·· :.I. I ~JI I !;'30 1 ll]I]!JilS
IJ!j : !JI.1!"1 (.r:f\-1 )4 .{Y:fJ
UOS J .. )rtr ]I ~;'i.( 1'liJl
l.U..1 .s r .l!IJI'I ,\.'l:lt·.J J3r1
'!Lit:. I l
. tJr; l.:•rtGO.'f~ H~)! H
t".~":lt t I •:or. lJI.WI 11Ua3i•l>
bt-8 1 l : "101\ (:l;J\1"! ,'fO : :1-!H
o· 1
[J • <.:
: .1.11·11'1 ·'ldl'lll H:)JH
~~·~~ ltf.'.:l<,;f-1 '>11.1.~-<1·
'lo)J II' t•
1;: ,.,
r6t;
Si.O I
'.'I~ I
II'Sl
:'~1 H'
o·;t•l•
rrJ~g ;:t=',.; c,
<;hl.'• , .. _,~..:,
l.(lf~
,,, ··~h
/, 1/,.-.
t-8801
f 'h_,.l ll t·r..r· 1 1
?t.·~ II
t:.t'811
S J..I II."'
•..,L '/,I I
(lt)Lii(l(l' :
101\ H:)N j t;. •,;
'H.>I• li .. N I R' II
101\ H.:tJ I L.. L I
1C'r.'\ tt: Ill "' • 8t:
·1<'1\ 11..11 1 r · 6?.
"](•/\ H.::J I f'. 'IC
"J!J,\ ll.oill ;::'II'
10!·. H.~ I i I· /,t'
'10/\ !<•H l fJ. I. S
1(!/\ II:"•N i lj '~)·,
lv•'-H.:•u: 8 · t-?
'10/1 li:.•NI ··.,·ll~
'lt)f1 H.:'l• I C,. 'lL
'K•I1 HJ,J I•' -::8
10'1 lkl•ll r · r:n
'I!)!'. H .~1·11 ~ · 1'1.·
'I ::1\ ltYII I '00 I
10/\ I I. •Ill II . '1(1 I
101\ H.:•~ll t.. J i I
lf)!\ Tlil.l
:1 I I -~~i-'<d ;(I~Hl
::1 ll::Hiu 1•1 : (N~I.L
.:!.:130 .. 1 "I HI );~JH.I.
::1• j('. ' J. .'I I·]\)~ j
11il ltJT:I:I 1n:?. 1
"·.:lO. C I : •J'l•JH!.>:Ii:!Hl .jl·ifl·j
r: Jl.t r:; ,r.•n::t•J • :nl'.l Tln
: .'d I .:.011 1~:"11 :tN"l
•1318''8 I r] :J::JI-' !-I
1 1~1.:1 LS::il :::.;o·;:•
•J:J'I:J•t~: I •1 ~1.::11·11':-'
!Id.J 1831 :•I•Jc·Fi'l1
•B'l:l:·.;t•l IH'!'1l•
'11 \-'.1 .::·{11. lllfll·ll·l"'
1-'-f\.lfll·lt'J s
'1-i '..!. J/·'1.1. .) I •10 l Wl j
f'1l.';
• . .:.( ·1·nr·JtJ•1 ~~ l lJ )tH31
fiL~
(;-.. .;~ : •• >J rj<\ I .'11. I N II· I . (1-'] l
3~Wtl :Ill
!~:tW'J. • l.ltJ In I d·l..,~l 11111
Jll('i>J : UJ.
Slt-lliJ. rJ1rl'loJitl"l-ll Hnl8
00' I .l.:.:!! :~J O '11-l·)!l J
flO' I l "ll.l :ttJP I
6t. :l!IH1 SS01 :r:t•J•lflo
66 : .li 1··1 1 I 11~\•'1~ :tl:-3'1
l_lrJtt1 1. ~1•j•1;H M')1
'-1~.b ·:
·~!; I
81/R I
111111 ;,~·[]111'131]
c,.-1. •• 1111-'l.'i I H!)IH
;:.CLL 1
•:rtt; J.l t.l I I Tll.lti .l llii
f:ULb I :')('II 1::18\1' I ;.f• l ; .1:'>1
0 ' I : J I I .Jl'l ."i~I.J 111'1 H!:'ll H
0 ' (: ~:·~-1 I N~\111 :-t?ll~'l I
'~I I t.l'l'
00!> 'J-"1/1 ll.~•N I ;_,. :,
t-1·11 I ]:)(\ H:)l·ll 8 ' I I
8i,>3 1 10fl H.:NI i •. L I
'J8LZ 'j{J/1 H:,lll o;·r.~
t·.::8r; 10:i H::>J-1 I I' • (.,5
I.L6t-10/\ tl:~ II 8 'St::
Ol.l? '10.\ H;•~l I :'. II'
r_.or.: 'I<)/\ H.:l:·ll I. !.r.
f.:. qg 1 011 lk1f>ll O'i:':;
1?.;J:. l Of1 II.>N I c -~s
L•'.lC I I !()/\ l-<1~11 ,::j' t·-:<
,;..(iS(.! ,.,,,, ll."•tJ I J'OL
f;s~.r i .1')11 H:l-ll :;·QL, c.-•. r-1 "101\ H.Jii I r·.:o
.:<lO'? I 1(\". H;:~l l f .• , .. , . ,_. ~·
l f::lli.l ,,_,,, H .. ~; I ::: . l';;
(ll(l'i I ·w,~ H~1ll 1 • IJI) I
11:-.:.8 1 101\ H;"~N I 11' u) I
b~~:6 I 101\ H.:l/'11 1-:. I 11
COI.r-.! 1.):•. I IIIJ
~;f.,j j._:: 311.1(\~f i .{hl'".l
':.l.. L 1 I '.J:U:JIIY 11] '11·1':/J
rllt/.rtnn · : .:11]0 .• 11~1·1(:!:111 I.
I :1-l<). (.. ~ 1•1• .~-f. I
~ J'lll'"''l II·HI: I .L
·Jfl.t:IS IIJ'!J. II!
•f { I]H.S (I]
1!.•":-::~rtt.; .:.10 ·1~1::1 ;:e;-: :-;;:;
1UCN
: -ir .1.1' ' J'·!l.l 1~1·: ''l 'J\-1
3'10N
: .jn.t::Js >~31\ 1 ;1 :··r::!
I
i.Ehl: I F.::,'f 11E I'Hl•[ --... -TE:~1' C·N f·;~Ti: : r,Ll. f;-;1~1:
.lUI~ t... :::Ou8 STr-~F:T I' 1 I IF : f• l ::::1-11:1 U1
TE;:;;· R1-1TE : Cl. 2l· ,·;rlL HI<
l•IIR• \T I'.IH : :,: H\.)UP.S
T:-::T EnRL; SH·~·:(IJ:;,;fJII.l•
u:,..,i. rF::.T ~u;·:P.T F~;FJ 'rlT
I l ~ F:tlr•l.
Lltll_l il• t:f:'l,,;; ·1: ~ :E P.ll-
L 1 :8'.' SH· TP 1 :;'f,;TE i ~;;I ~:.~LI: Fl Or\ f ·
I:,:., 1 L.:• o<.•l\'o' : ~:n· SUI tf
l ~·: 8'/ r ,·II IULHR
TH 1 -:-;;Tr-fff. 'f:: l 1·1• ;J.l: n .OnT, , ;-;Tl:t:;oF:·,· : HIIN''L~-o~: :~·r·r~•·t...
L .1:·;•1 ~.:n·
1 H l · S !r1H. '· S I I r .1.1. n c >roT >
(';;Tl•::N<'. : :-; fl :.;Ui II·
L 4 : <JI "11!1111 ~~~· n: 1 ST'~Tt: 's 1 i••.:LL 1 u:rlT, .;,I F ... ·1~: 1 : r1r::·J•JI AF: :::f·,,~·F.
L 5: D 13~' I -2 'TI~: -::.;r..,Tt:: (:J[t.;•::: E FLChT>
t.';.,_Jt;•:;•.;R·. : [1!:::1 EIISIF~ f·11ti
L 6 :r•I::r· ~.:;-o.~ H: I -S"I ,;lE C':;I 1:-.~U:: FLvi-\T l
i ·" I'Lo .• llP.'o' : 1i I ::~!:fi:-':1-J• r·,;H
L 7:[1!!:P 'J-t. r~:l :·r •• TL ;:;ll~·:u:: t-t···I-\Ti
•.'n'ID ;c_,f" : I• ~::·H-.NSJ .F' r·;,1J
L 8:[1\U: /-:J n~ I : :T .. TE u" 11~•-·U-: H.""·r >
• .-.~n·,,.;;•P\ : _11 U Erl! ·:£.!( F,.; 'I
L :.! : !37 I ! l.L
TR I ~:Tt• rr <...; llh!.F 1'1 '• ol • •'llll'•·O~:; : I·H I Iii: ~;l11-JJ:"
Ll u: ·~I F I J.L
'::"R r-:3fi~Ti <~,Ill';\ !: II,:., I' • ··~n .. :(,t-:'.' : Pll'llr-:; ::;un;:·
(IIJTf·IJT t-:f.LHY :-..F'll.lf·
~: 1 :8'' ::in
T'il'l:.:
STniii•Hr:l•
l'lCIH li~l.L ·: •. I n~a :fl
Tt~IH: 11:
L Jo_,iJ i I • :11 iiS~"•F. ;;U·t;:;
i. I :tlll.:L hi ,..~N
L. '.): f'l IEL i,LflF<II
L i): I l•El HI 1-\F.i l
1. 1: r u~L ,,f.,.f:i·l
L 8: riJEL -'ll.r·F.I-1
l I :f;;E!i~':;IF; '1Ul tti.HF:.'l t. ~.:. :r:r l:;t;P OIJT Hlhl-:1:
I. t.. :f£q3~>l-. ·All ~;iJ-1F-:il
L 7: ;-:if:l·~·:r·•~ OUT •·1 • ,Ril
1. s :m:1::>vf, vur ~~Lrl~;; 1
l ~JL• ~:: ITr nl.HRn3
I Sf• I if\OS:":; !•F•£:3 Fl-i ( L
I :·;[• DEt>P.[• ~ kl :::·· 1"1·\1 L 1:'.r' ,,.r~r··;1-. LErll: FHIL
I S[• \II H<L'; fH I L
I t>b 11{>:\C I •l.Hf-:11::.
r \Ll.: 1_;P,• )~J . .> I ()!.LEi ''f 1-'111 L
HI I.: f•£(:P.r• -:·uu Lt 'f F;-; 11.
1-1!.1 : Fl.OH '·oLLE1''f 1-'n 1 L
F: .~ : ·~I ;::'fj'·
"J .,., r::
:~:THI·II't·ti-:L•
N;)}o.r·I!~U , <;Lo~:i:l•
ThNI: 11: c:.
LJi:OLII!• ~.l:fl:":."·F; ALP:::
L 3: t'Uf'l. ill •\1-:tl
I. 5 :FIJU. ~Lflh11
L 1):1'111.1 ill.hP.I1
1. 7 :FUEL ·•I. f IP.i j
L 8: Flit:::. ilL'IP.II
L 3.r;!-]l.~.: P. QU'I nt ,.f..'il
1. c ::::Er:·~Gl: .:•11T ;,L;-;P.'I·t
L ,., :: ;I:ti:-:o" 0UT 'ol ...,F:i'l
1. 7 :st~r.~or: ouT 1-1I.Afdi
l. :;c: HENBOF. 011'1 nL•ti<:ll
1 Sl.• s 1 n· , ,u;F.r·;:=.;
1 ~>I• t'if..:v.j:-c> l 1-'t:-::'; Fr1 11
I ::;r1 t•r(;~:ro ~·];. CS I ; 11 L
1 ,;r, ''Hl'(>r: Ll:f;l: r" 1:.
l :o:r• t.l~ I Ht:f:: rill L
I Sf, rlm.:r r-.l.llf,IIS
ni.l : GP-<1S~J r ·~;tl.D 'T fr11 L
Ml I : T1E• :r fJ •X>L.I t:• T FAlL.
•~LI.: F! OW o.'OUE1:T f -\1 L
r: 4 ·'-'''1.."'1" ll.l. rl!.•lfj•l
l a' I F.:
:'::Ti •Nf•H~;f•
I•K.RIInl.l ·.-<',f£11
T,..;I·H: 11: NI)IH
ill-lnl'll nl.liRII.J
r-1LL: 0\IEf:l' ILL 11L•1f-':l l
1-1LL: H Jr::H l•Ri)l.ot•:T r .I., i/·:11
;,LL: n." n. a'"' .. , nL•il-:1'1
;::t i;;F. m!.1 HA~ ::>1-:·: Ul
I :[ol:::f• 1 :· ~ ~: , ... HTI ~~ :•·!}-:\' '•/;..;[ tW H:l ~i .. uJd . :Ll.:!f I 2 ('(-} I
o:·r~TE-;oP.'.' ;.; I~: ! LUI. I r li'TSl<
.3 ~ : [ o! f;l• 3 <I Ff I
•.·nTJ::•>··R'/ .-~ J }: Ff ,_.,, r n:·t ER
5 •I: [oJ ::01 " •• Fll
i ··r~TL).;( IP.'o 141 J.. FL('i·J 11£TG:
!. ~, :[Jl::il· 'I-'d Fr1
•::'nTf\;r)F:\ til f-: F!._,_ •II 'a:. 1'1 :F:
fl
IJ
I
FVF: I ::C;L• ;.:['!UP
FV~ T,f·F: liHo··,ll"'l ,...,::::n:·;T
•;;-,,~ul•l·l h:.: .. {'jl r·.-rr , u.:..;L ·/ \lf ,, ·
1·10:...:1 E 1-\ l f : .. h• ;r
1·1.-\::: l . I 5 Ill N: U. ·:··~
V?ii-OP. F·k(;( f': :: Jcl: T'/H:
IIOI~E
r'Nr1l .'.':'-:I :3 T !1'11::;3
I'II'IE: I C: 00 1-111
l•EL...;'.' Jlll'JUl ES :
1 ll.'l;E~·T H !•:at CF.'·If~:
[• i S.-18! F.l•
I ::.;[J Ho: >L Tni'IJ.l
!C• f'P FL IlL ,._ .• h
.. ..
Ul (JJ Ul 11.:' Ill o:: n::: IJ;;! 02 01
u:·~ rr:' 1):'5 n~, 1]:?
Ll•l 0·1 11·1 1),~· lJ.'
0':'. 1'15 IJ':o o~· 03 rJc Oo Ot 02 0:3
0? 07 lJ? u·-· "-04
08 •Jd Cti., 0? Ll·l
P.R
,Ill
LIU
till uu uu
Ull uu uu
I S[• ;~I F:FL•!~ I IIL.:TL:J-: l'lfiF'
1[1 :-i!J.l "L I~LI·J LnBEI.
25':,07
2 "i>otl'/? :J .'4flllt',
•I ::·• .• uul
VI~::>!-• 1-2 F
:•ISP ~l 4 F rJ!m· .-,-G r
CJ! ::-:r· '1 8 f
t::;[o r'liLl. ,;~:Hl•l HI·~·;J' llo-IP
I ~ 'j 4
H· i H IH I :nH i1HH t·1HH hri
01 501 9111 )(11 U IJ o:: ')(t:' ')02 J(J:-• ll u
U8 !:10~$ 90~ ;j1_1;') U II 2
04 5n4 qo4 )04 u u 2
1)1-, ~LI'.:. SIO'~· 305 II U 3
.J6 ~-ot. 9••t-:::ot. u u ., ._,
J7 S07 G07 ~U'l U U 4
00 '.oOb ·::.,J8 ·:•J8 U lJ .;
Lt;fr:L. Tr-18LE
1: lm-\.S:_; l•.irll::.t•
2 : F:l I :1-JIJ~<
1 : F:El;uu-~1\
.::: l1ll1 ···klll•l::.
5: rRnlJ UH
o: oi\jLio
7: D~otCE
8: Sl Ll!f.F:
9: fll 1'1-l[J..::
1 u: !;LJ:.N[hl
PH• SFTUP
H•lC ·IEP.S I ,JII: U l . U 1
\ln\-•)1< f:RlH 'l·:~::·_;t_,F: l'Vl E
NOliE
i-l':O('E:;SOP. t \I!ITP.(II. [.l.,:Et.:
HOllE
~;L.;..F:i \ H 1 ;_;T{)f\'.' ~:Ehi!-<T
::;·::-:Ti.:tl "\l.o ,1~1'1
\-'rii'I:F: • >UT 1-1LIG 5 . ~·ul ·3 1 1 : l b ~111
f·P.I NTEP. F.f..RC·l< ~\\Jo'; 5. :20 l 8 I l : l b HI I
Ito ~ " • •-ENl1 • .-: ~ • •
Hli-11-:l'l Hl~:·f·A·:·.-RU-'UI:I'
I N-TH!'IL iiLHRI'l -
T I: •._II•H.l2ni'l:L R
J'•f.L I Vl:P.'i 1·1\:':Ef•Ll•
llr-iR :iO, 2lJ1.3 I): 18 HI
l•E•. _;: 1 • ~0 l '! ~~:-II fl'l
• A ~ ..: "' ENl• .. lot .. :~ ..
, ;L~l~l ·1 I l\ ·.::;1, •Y.-. !-. E~ .+.T
I 1•1-1 ril-l\' 1-\l.iiF:I· I
T '•:UL H:f.!'lllll'l
L•LI. ~ 1 il:'.f' ,· (•lEU ot:\' ;.:,UI_; 18. _U I·-; ':!
0A' 11'1 i~~f; I '5. ?0 I ~ I~· ·:;to hi
ro,IJI' •;,. ~:u 1 8 ·~ 18 n·1
.-ofr; .... /';. ~ El·tY~ ·, :.,-.. .,._ ..
,,u-1RI 1 111 :~rnx·: F:EY' ·)·n
I I~ 1 nl h. Ml.r-1~:! I
1' ']:P\u•lh•\ :J''
~t • :tt' "' ~ l~Hl• r
• 1't • ....
• J/ 1"
1·1\;"1 10:0 I ? 101.: · ;:::;:: ::•tli-J
H.:l~'l11 .l.llO :~l· ;~n .. _;
H•• ;:. l: Ill ;-• IOC: • :~.;:~ ~l•(H
1-l'ili'(IJ 'HII.:l
1-J'·•:! -:!.:i~;N::USI•J
.::; l dS I 0 : c; 1
lJal·!'lH ,)o{Q~_:IJJ!;
t.JI:I tO:(II :::to;: ·,_;.~ 811''
1..))-{rr Jl-i 'l]ll:i
l·llc' ?(;: 0 l ~I (l,'~ · ••. t :~•ilH
I·J.'fl r [1! 'l 111::1
:l.'•H-J!:' ::II·!'JntJr.J~-'
iil-llflr.tf.J'-i I b : r I
r .J:·JI f!H ;-l(•:::r.JJ:3
t 111 IU: n 1 .-111.::; ?? ~~nb'
[ •. l~l\-1'1'-' I:l: 1·1
I!H Hl:fl l "!(It,: '00 ~f'l'' t.JaY 1r-1 ·nru
Il.lm> -us
H8 IG :t. 1
tJ;_~'.rJit ,.,, ·.-:rn:::
1-Jh' tn:c11 .... 1u.: ·;:-;:-~~~~~~
I J~·-n~' ll!O :'{• ~~~~·!':)~:
(.j\1 q I :I] I '' l rJ.--: •• ~;;: ')llH
~~:~1:-'-lY ·m11 1
t·l>~ ,-, 1 : ., t ::-t c•;:: · .~,::: ~-·nt~
!-1.'~1-ilr' TJilJ
3.tl:-! i"'· .':l'''lliJ.IN'rl
~"'illHI !'-' i,8 : (; 1
t.J.':I' !111 :~o:·:l·l3.-:
J•'V·-11-1 .:.:~o.I .. :IH 1!.'-l\'111
IJI:" !0:01 -:;111.:: ·::::~:PI-!
1-1.'~" 111 J.llO :-{'1''1.'!~;
(.l\-1 80:01 •'10~ ' .. :._: ,_,i)'cl
ld.';ll-f1\-! 13tl=l
utn~ . .; .Jls
dJ:· t.u : t -~
-· I J>l~-'"1' I ·"'' 1: 'I J::!:-3
.I . .' I· .. :Ekf :,;.JO.I.:~:! It I .J>IIi'J'i
J
~~u~F:~·; ·~ L. H >P. ,· r:Ff · •r. r ·
:-::Ell:.:· -~t I~LrlRf•J
L lj :{It:'::!= 7-8
[•ISH H: 'l P. f.'A'I
fii[L t.Lr~J.:n
t'llJo:; ':.. , ·tll 2 I I : ll ' I til
fUEL Hl.r\F;J•J
Al.i•·; .~:-,. ;;.'Lil'! 1 i!: 13 ;;f·l
FUEi nl.nRt I
ill!\: :·::: . ..-!III.· II):G1 Hl'l
!t\ • 'It •• ... r.f·'r J '"' •· ~ * "'
HL11?II IIIST·'F'.' J-.U"..>I<:1
-:'>EIJ:·:\1R --1I.r1RI:
!. 9 : u'/ I· I Ll.
l I ~ l N• > Sill l}
f'LIEL ; .L~tRrl
;.Ill•:; ''·t. 201 .' Ill: IIJ i~l'l
t'F It ;(.)~ l)ll f nLi-\Rt·i
i-1U3 ~·::. ~U1:? I il: 01 ;;M
.. ~ ~ 'f-... El J[, ~ · <lit. ... ~
1\Lt!RII H l ··:T• -J.:·; 1-:£!-·• d·: I'
----:·~u-~::.;oF. nt.. ;RI"l -
LlO :~1 l l LL
1 1 r tr•·:; s:.~·n·
FUEL ...,L1-1R1 1
1-\l_t~ '·,. :!Ill ' 11.1: 07 til'!
Sl:l i::ie.Ji OUT ,o~J.f\.1\i I
1\UI: '22-.lOJ:c IU:Dl ,;fl
.... 4 )I.. ... ~ t."f.lf. .. .,. " ""t •
-~
• ::.:EI~:.;·.>~: HL• ,pr·t
L I : fl'l : 'Tf'
:OHI f.l:f·tf·
FUEL nLA~:r I
~ILJ(; l'(.l. 201 { 'l: :JI t11"l
HP.('(:· .:trt~ r111 H~?u3
.:;.i.'.IU I'(T \/~1 r·rUII f"l\1~
l'l:.l:-,·• ;,t" 1 e l-1 c;, 4: ~~·u"'
,~u.-~ ~·o. 201 -~ ·;,: 3'.l 1-\1·1
: :·.-:.:TI.Ii ~ ·:1 ;.;TU:: r:LI <"!-: !'
Rl.l. l UIK'T J • .-r.~;_; I·:'!P.tl";l
F:El n·.· uvrr·uT TE:n
i 1U•,; 2n. ,;:o 1:: ": -''~ fit·:
k 2 : 'll :·:n-
T·, f£:
:3TnNftriRD
IK>RI1.,Ll.'.' r::t.<>:TI•
THN!: II: ··
L !IIIli [J Sl 1-J:~i.'F: 1\Lil:~
L 3: l"lJLl HL...,r;rr
L :.:r.ru. ,;u-;1<:1'1
L 6: FUEL rll.i-1F:Il
L rt : F'JIEI. Hlhl-:H
i .. : t Ut.l , ll.rtf;ll
L 8 :f:r.rt::>·)t-: •HIT hL;-;~:•r
L ':;: ~;t:J'l:.:c;J< , )!JI Hi • ·,pr 1
I b: ::C:Er~~-:uP ,)JJT >ilhP.f·l
L '7:: ;f:I~;:;,)F vUl nlnk'l-1
L E:: f,f.f r:,;· •!: <>1.11 r~Lnl;l 1
l :;>[I f: I TE i-ilnF:rt·;
ISf1 •.;R0:;:_: l·f.ES rniL
I :'::I • l)E(>kl• 1-'F:E:·: f'~->.1 L
1~-1· l.lr-~Pc)lo· LF)·,J: l'ollL
i. 'I • 11p r·Rr·.-: f,..; I l
I :;(t tK~SI.:. ~\lllPII~:
,.:;1 1 : •.ii\'11SS •.'· >LLE; :T n d I
rll.l. : f•CGI-:1• ,·-. ·U .T ,-T ~1-i ll.
nLL:flJit.,, <·.;! U• 1 FAll.
;·,Rl·-,·> ·:J'H ~fit :;";:•'/11;;
~t~~f.7.i 1II ··'· r n ..... n tn:\i'
F: ,1 ,., :::.f l• I d
,··n ·r·;-·_:u6
,.,,It': :-:0. _u! -11·1
: · :.::.Tt:l·l ;:;'i'dTII., ~:U i ·f-.1
nLl r'1.JI·J•·T li-'l~.c; r·r,+:rhL
;·,CJ:;\.•1-: 1 oUII<I I
L ::.: '' :.;n· ~;n· ·.-:.ul1f'
FUEl. ;,l ,..~;II
hU(i '20. .:0 l. j ·.;·II I ill'l
Sl.hf' ·P. , ;L,~l :; I
1. o.l: '0! I 11Nf'll ILrlr~
I IHNI JI_,;P. ~·~=-H·:·E
r'U£L ,,L, ·RI·l
nUl; :ltj. ::-u 1 .I ·:•: •1·1 ;,1·1
hR•'~) .;,11o Pill :1/:'/03
:-r;~CJ f11 \_/~((IUf• r-f\HJ•
1_;.;,1 .,,. -.f i 0: ].j
,··f\ ·::· :•)(It:.
HUo; 20, ;,:Cll J ':l: ·l':o ;-,1 1
S,S11.11 :=:Tr~TtJt: ~E~.:Y.l
L -1: FUEL riLr-'•RI·i
,;tt·J: A~ nl,.;~:n
I. 4 : oj 1 hi'·H'I' ILHF.
,.,1111UL11I< ;?.f nCF
fUEl t-~J.,.,f\1'1 r~u.:, :::n. :::n1 :; ._,: 4t. t-~t·t
-:-:rll:=nr: 1-il iikf·l
un:••t r ru
I• I f'l II•; ::a It II
FUrL. , 1LnRI•1
,..;IJ•": 2(J. .:111 '.i; --1,, .-11\
-St.:ll:':i0l~ IILHHI
L ;:: : 8'? H tllliJL•,F;
l'ol·ll-1111 ~~~.' ;::r~-;t'!:
FULl. 1-1Lrli-JI
nUG ~m . .: •13 <t:<)O Hl1
:':Eil~\\lF; ,I...;h1"1
L ~l: 157 F II. L
~-r t:·r r~o.: ::Ltl1~·
Fl lEI. 1 o!.tiRt I
i;U:; <:'IJ •• ::01 ; 9: '51 1-1t·l
:.:;f.ll:·:·~·k ,;L,..Ri 1
L ::: 8'/ fit II ;,J[ ; .~~
niJtiULAI( :-;h~' 'E
FUEl HL,...Pf·i
hi.~: ..::o. 2L) I l ,, : L I 1111
~~F.(''. ~· .. • '" >-"?U.j ?6'1,~ I•JT \/,_1 lol.•ri rlllo..
f:,\1•"1 ;:,I hrld
,··~ ~13.:lfJt•
HU•.: :?L•· ~·ul3 ••: ~ •. : i-ifl
;:;', :', li.tl ::. l • .r t b f.Ef.·d: I
L .~ : t-UEl. rol.r,F.I1
~':E1 1. ;•p , ol r-<~.1 i ·-
L '=·: r•r:-::r· 1-.;: fo I :c:;PI.Il:-il~F: I 'rol11
Fl. if" I t;L;::.P./ 1 r~I.M, :o. ~o 1 ·, ·': 5 ·; nr·1
:~En: .:;i: ;.:,_..;r~r-1
L o: !II Sf· 8 .!
fo I :;f f:t1.3EI-: F h'l
Fut!. ,.:,t.nF.I1
,;lj(; ~·t) . .tOI ~ =.:~,-< ,...H
_:J rt:On~. ,l.i\RI1
I. •; : L• I. ,f· '"•-t.•
I 1 :':t EfolSEI< H1N
HIFL ~-oi.,:,RI'l
AUi, .'ll. _'I I .) Ill: IJI'I df I
:~F.r-L ... F.· hi -"~:11 L ~ :rd~:~ 7 h
11 i :;r t:n :r;p f "'I
Flli:'L III.Hkl i
,...lJl; :20. ;?1j! 3 IIJ: Oi' i-111
• • SEI J:~·~:i' fil tiF.II
1. t : 8" :::-rr
~:rr· ::...ui1F-ruu flli;P.r'
fii/G :•11. :?01: llj:ljt.) rl!l
:·:l:N::.:d. ;;(,, tf.?l I
1.. I : ~:)'/ ~;fy
Slf :;1v·IF
l.if-J(;-: •F: \)UT ..;L,.;P.I I
roll<..: ~l• . c~O 11 I 0 : u6 t·1 I
II'! qG : I) I r: I u.: · q;-''ltH
I fi>t IIi 1110 '+•~: '113.:=.:
tJI-!,i ;'{"J~]I,'i 1~ l •l
8 L ,if.!i•I:~ I
Wi'•·J•! .'J•r:-·•rJ::
I ·~"' ~~~ t: t 11 f: 1 C·~· '1 '·~ :"11"117
I ::j~l'l\cl ,11l!J ;.{(:·:;11]:'3
11\-l.j .'i 1: 'I;' I ! :I •.:
;t-S i~!l •l: /.. '1
~ l~l•";'-'i"1F'l.1S
IJ" ·~(J:nl c;o:: 'll.:' ::·w
I J'JI-'11-1 .lllO :·{':):::::n•:
·iL~ IS • II I ! t 1
'11 1 I ,'.tl : h I
I k!"' I~ :·Pfn:tS
1-111 ?0: n 1 ' l(k' · n.~ !•1l~j
I.JaH·J•.• Jrv· ::IC·S'rJ;lr~
IJI-I I :H:~t·J3..1:c'l•l
1•-r ;: : '•I :.., '1
lf-1''1\-! ,'j <::·:tJ:f:;
:.-"'; n l f I !I·~ '0(. 'lfiH
.. 1111111 • li1P .·W"'i .3'0
jl tm~ il:•
11S lt .. : 1
ll·'lt'IU d•.'.-11'1!"
IJII ·;lU:U I (II);:' '11•~ !.1n11
H:-1"1" 1.110 .·wn.ri~-:
t·JH.·J :.:!.1' ~·IJ.•t:: I •1 .:-1 d:.\111:'; 1
I Ji114'1\-' : V :.!1-13~-:
SWRCB, January 2006
Spill Bucket Testing Report Form
This form is intended for use by contractors performing annual testing ofUSTspill containment structures. The completed form and
printouts from tests (if applicable}, should be provided to the facility owner/operator for submittal to the local regulato1y agency.
1. FACILITY INFORMATION
Facility Name: Mt Vernon & Columbus Arco AM/PM I Date of Testing: 8/20/2013
Facility Address: 2698 Mt. Vernon Avenue Bakersfield, CA 93306
Facility Contact: Monty Hawatmeh I Phone: 661-703-7273
Date Local Agency Was Notified of Testing: 8/5/2013
Name of Local Agency Inspector (ifpresent during testing): Ernie Medina
2. TESTING CONTRACTOR INFORMATION
Company Name: Confidence UST Services, Tnc.
Technician Conducting Test: Bryan A Self
Credentials 1: 181 CSLB Contractor X TCC Service Tech. 0 SWRCB Tank Tester 0 Other (Specify)
License Number(s): CSLB# 804904 TCC# 8022804-UT SWRCB# 11-1756
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 4
Number, Stored Product, etc.}
Bucket Installation Type: 0 Direct Bury 0 Direct Bury 0 Direct Bury 0 Direct Bury
X Contained in Sump X Contained in Sump 0 Contained in Sump 0 Contained in Sump
Bucket Diameter: 12.00" 12.00"
Bucket Depth: I6.00" 16.00"
Wait time between applying 5 min. 5 min. vacuum/water and start oftest:
Test Start Time (T1): 9:15am 9:15am
Initial Reading (RJ): 11.00" 1 0.50"
Test End Time (TF): 10:15 am 10:15 am
Final Reading (RF): 11.00" 10.50"
Test Duration (TF-TI): I Hour I Hour
Change in Reading (RF-R1): 0.00" 0.00"
Pass/Fail Threshold or 0.0625" 0.0625" Criteria:
Test Result: X Pass OFail X Pass OFail 0 Pass 0 Fail 0 Pass 0 Fail
Comments -(include information on repairs made prior to testing, and recommended follow-up for failed tesls)
CERTIFICATION OF TECHNICIAN RESPONSIBLj: FOR CONDUCTING THIS TESTING
I hereby certify that all the infl)l"mation contained in thi..'l ref)8f"Ns truA, accurate, and in full compliance with legal requirements.
Technician's Signature: ..... ~ I y fJ..., 1"'.1 r ' -I \ r 1 , ~ ~ ,
1 State laws and regulations do not curren
may be more stringent.
Date: 08/20/2013
by a qualified contractor. However, local requirements
I
I
L 1
-
87
ST
P
,
20
8
se
n
s
o
r
L2
-
87
An
n
u
l
a
r
,
40
9
se
n
s
o
r
L3
-
91
ST
P
,
20
8
se
n
s
o
r
L4
-
91
An
n
u
l
a
r
,
40
9
se
n
s
o
r
L5
-
UD
C
1-2,
20
8
se
n
s
o
r
L6
-
UD
C
3-
4
,
20
8
se
n
s
o
r
L7
-
UD
C
5-
6
,
20
8
se
n
s
o
r
L8
-
UD
C
7-
8
,
20
8
se
n
s
o
r
L9
-
87
Fi
l
l
,
20
8
se
n
s
o
r
L 10
-
91
Fi
l
l
,
20
8
se
n
s
o
r
1
-M
a
g
Pr
o
b
e
2
-
Re
d
Ja
c
k
e
d
el
e
c
t
r
o
n
i
c
LL
D
@
Re
g
u
l
a
r
20
,00
0
ga
l
.
@
Su
p
e
r
12
,
0
0
0
ga
l
.
ES
O
n
Mt
.
Ve
r
n
o
n
&
Co
l
u
m
b
u
s
Arco AM/PM
26
9
8
Mt
.
Ve
r
n
o
n
Av
e
n
u
e
Ba
k
e
r
s
f
i
e
l
d
,
CA
93
3
0
6
r-L_