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FMC 2013
MONITORING SYSTEM CERTIFICATION For Uve By All Jurisdictiom Within the State ofCalifomia Authority Cited: Chapter 6. 7. Ilea/til and Safety Code; Chapter 16. Division 3, Title 23, Calffomia Code of Regulations TI1is 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 perfonns the work. A copy ofthis fonn must be provided to the tank system owner/operator. Inc owner/operator must submit a copy of this form to the local agency regulating UST systems within 30 days of this date. A. General Information Facility Name: #7776 Howard's Market Site Address: 3300 Planz Road City: Bakersfield Bldg. No.: ___ _ Zip: 93309 Facility Contact Person: Omero Garcia Contact Phone No.: 661-393-7000 ~~~~~--------- Make/Model of Monitoring System: Veeder-Root TLS 350 Date ofTesting/Servicing: 8/14/2013 ~;},~~P~~?.~t.~~o~d~~i£!:c~~~m!~~!~~~'~<~!ified Tank ID: 12000 gal. Regular Tank ID: 12000 gal. Diesel [x] In-Tank Gauging Probe. Model: 847390-107 W In-Tank Gauging Probe. Model: 847390-107 0 Annular Space or Vault Probe. Model: 0 Annular Space or Vault Sensor. Model: 0 Piping Sump I Trench Scnsor(s). Model: 0 Piping Sump I Trench Sensor(s). Model: 0 Fill Sump Sensor(s) Model: 0 Fill Sump Scnsor(s). Model: 0 Mechanical Line Leak Detector. Model: 0 Mechanical Line Leak Detector. Model: [x] Electronic Line Leak Detector. Model: WPLLD W Electronic Line Leak Detector. Model: WPLLD [x] Tank Overfill/ High Level Sensor. Model: 847390-107 W Tank Overfill I High Leva! Sensor. Model: 847390-107 D Other (specifY equip. type and model in Sec. Eon Pg. 2) 0 Other (specifY equip. type and model in Sec. Eon Pg. 2) Tank ID: 12000 gal. Super Tank ID: [x] In-Tank Gauging Probe. Model: 847390-107 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 Sensor(s). Model: 0 Fill Sump Sensors(s). Model: 0 Fill Sump Sensor(s). Model: [] Mechanical Line Leak Dcccctor. Model: 0 Mechanical Line Leak Detector. Model: [x] Electronic Line Leak Detector. Model: WPLLD 0 Electronic Line Leak Detector. Model: W Tank Overfill I High Level Sensor. Model: 847390-107 0 Tank Overfill I High Level Sensor. Model: 0 Other (specifY equip. type and model in Sec. Eon Pg. 2) 0 Other (specifY equip. typs and model in Sec. Eon Pg. 2) Dispenser ID: 1 & 2 Dispenser ID:_ 3 & 4 lXJ Dispenser Containment Scnsor(s). Model: 794380-208 W Dispenser Containment Sensor(s). Model: 794380-208 [X] Shear Valve(s). [x] Shear Valve(s). 0 Dispenser Contairunent Float(s) and Chain(s). 0 Dispenser Containment Float(s) and Chain(s) Dispenser 10: Dispenser ID: 0 Dispenser Containment Sensor(s). Model: 0 Dispenser Containment Scnsor(s). Model: 0 Shear Valve(s). 0 Shear Valve(s). 0 Dispenser Containment Float(s) and Chains(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 djspensers, copy this form. Include infonnation for every tank and dispenser at the facihty. C. Certification -I certify that the equipment identified in this document was inspected/services in accordance with the manufacturers' guidlines. Attached to this Certification is information (e.g. manufacturers' checklist) necessary to varify that this information is correct and a plot plan showing the layout of monitoring equipment. For equipment capable of generating such reports, I have attached a copy of the report; (check all that apply) 0 System Set-up x Alarm history report ' Technician Name (print): Kristopher Karns Signature: ---~:::.......lt6......._...:..1.~~~=:::....:..----- Certification No: 834106 License No: ..::8:::.04:::9::..::0::::4 _______________ _ Testing Company Name: Confidence UST Services, Inc. Site Address: 3300 Planz Road , Bakersfield, CA 93309 Phone No: 800-339-9930 Date of Testing/Servicing: 8/14/2013 ------- D. Results of Testing/Servicing Software Version Installed: 15.01 -------------------------- Complete the following checklist: [i] Yes 0 No* Is the audible alann operational? X Yes f l No* Is the Vtsual alarm operatiOnal? X Yes f l No* Were all sensors visually inspected, functionally tested, and contirmcd operational? X Yes O No* Were all sensors installed at the lowest point of secondary containment and positioned so that other '--equipment will not interfere with their proper operation? DYes @No* If alarms are relayed to a remote monitoring station, is all communications equipment (e.g. modem) N/A operational? i[i] Yes 0No* For pressurized piping systems, docs the turbine automatically shut down if the piping secondary ON/A containment monitoring system detects a leak, fails to operate, or is electrically disconnected? If yes: which sensors initate positive shut-down? 0 Sumpffrench Sensors [ x] Dispenser Containment Sensors Did you confinn positive shut-down due to leaks and sensor failure/disconnected? [i] Yes; 0 No; [i] Yes 0No* For tank systems that utilize the monitoring system as the primary tank overfill warning device (i.e. no [_] N/A mechanical overfill prevention valve is installed), is the overfill warning alarm visual and audible at the tank fill point(s) and operating properly? If so, at what percent of tank capasity does the alarm trigger? I 90 I% DYes* 0No Was any monitonng eqwpment replaced? If Yes, identify speclftc sensors, probes, or other equtpment replaced and list the manufacturer name and model for all replacement parts in Section E, below. 0 Yes* ~No Was liquid found inside any secondary containment systems designed as dry systems? [i] Product; D Water. If yes, describe causes in Section E, below. Jx YP"-I I No* Was monitoring system set-up reviewed to ensure proper settings? Attach set-up reports, if applicable. X Yes ( ] No* Is all monitoring equipment operational per manufacturer's specifications? *In Section E below, discribe how and when these deficiencies were or will be corrected. E. Comments: F. In-Tank Guaging I SIR Equipment: [x] Check this box if tank guaging is used only for inventory control. D Check this box if tank guaging or SIR equipment is installed. This section must be completed if in-tank guaging equipment is used to perform leak detection monitoring. Complete the following checklist· ~Yes D No* Has all input wiring been inspected for proper enter and termination,including testing for ground faults? X Yes No* Were all tank guaging probes visually inspected for damage and residue buildup? X Yes No* Was accuracy of system product level readings tested? X Yes No* Was accuracy of system water level readings tested? I No* Were all probes reinstalled properly? 1 x Yes ,_ · ~Yes D 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): D Check this box if LLD's are not installed. c .. . he foil heck!" ....... [x] Yes 0No* For equip. start-up or annual equipment certification, was a leak simulated to varify LLD performance? (Check all that apply) Simulated leak rate: ~3 g.p.h.: 00.1 g.p.h.; 00.2 g.p.h.; DYes [x] No* Were all LLD's confirmed operational and accurate within regulatory requirments? t1xJ Yes No* Was the testing apparatus properly calibrated? DYes No* For macharucal LLD's, does the LLD restrict product flow If It detects a leak? X N/A [x] Yes == No* For electronic LLD's, does the turbine automatically shut off if the LLD detects a leak? ON/A ~Yes UNo* For electronic LLD's, does the turbine automatically shut off if any portion of the monitoring system is ON/A disabled or disconnected? [x] Yes CJNo* For electronic LLD's, does the turbine automatically shut off if any portion ofthe monitoring system ON/A malfunction or fails a test? ...., ~Yes QNo* For electronic LLD's, have all accessible wiring connections been visually inspected? 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Jt· II u.oo oj'J . ~) ,·;r-;J.S ,,;,,Lf; •.:1-1L;"-; ,;,...;L.S I i!CitE::: o:;f;LS ! N•'HLS N~G F ,. + ,.. ~ • !:.1·1[• k ~ • "' " SWRCB, January 2006 Spill Bucket Testing Report Form This form is intendedfor use by contrac10rs pelforming annual testing of UST spill containment structures. The completed form and pri/1/outs.from tests (i{applicable), should be provided to the facility ownedoperatorfor submittal to the local regulatmy agency. 1. FACILITY INFORMATION Facility Name: #7776 Howard's Market I Date of Testing: 8/14/20I3 Facility Address: 3300 Planz Road , Bakersfield, CA 93309 Facility Contact: Omero Garcia I Phone: 661-393-7000 Date Local Agency Was Notified of Testing: Name of Local Agency Inspector (if present during testing): Esther Duran 2. TESTING CONTRACTOR INFORMATION Company Name: Confidence UST Services, Inc. Technician Conducting Test: Kristopher Karns Credentials': 181 CSLB Contractor 181 ICC Service Tech. 181 SWRCB Tank Tester [ 1 Other (Specify) License Number(s): CSLB #804904 ICC #5264406-UT SWRCB # 09-I743 3. SPILL BUCKET TESTING INFORMATION Test Method Used: (8) Hydrostatic CJ Vacuum 0 OtJ1er 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: [ 1 Direct Bury 0 Direct Bury 0 Direct Bury 0 Direct Bury 181 Contained in Sump (8) Contained in Sump lEJContained in Sump [J Contained in Sump Bucket Diameter: 12.00" 12.00" I2.00" Bucket Depth: I2.50" 12.50" 13.00" Wait time between applying 5 min. 5 min. 5 min. vacuum/water and start of test: Test Start Time (T1): 9:00AM 9:00AM 9:00AM Initial Reading (R1): 11.00" 11.00" 11.50" Test End Time (T F): 10:00 AM !O:OOAM 10:00 AM Final Reading (Rr): 11.00" 11.00" II.50" Test Duration (T F-T1): I hour I hour I hour Change in Reading (I~,-R1): 1.00" 0.00" 0.00" Pass/Fail TI1reshold or 0.0625" 0.0625" 0.0625" Criteria: Test Result: 181 Pass OFail 181 Pass OFail 181 Pass 0 Fail 0 Pass 0 Fail Comments-(include iriformation on repairs made prior to testing~nd recommendedfollow-up forfailed tests) CERTIFICATION OF TECHNICIAN RESPONSIDLE FOR CONDUCTING TillS TESTING I hereby cert~fY that all the information contained in this report is true, accurate, and in full compliance with legal requirement.~~ Technician's Signature: ~' k~ ( Date: 8/I4/20 13 1 State laws and regulations do not currently require testing to be performed by a qualified contractor. However, local requirements may be more stringent.