HomeMy WebLinkAbout#781 FMC RESULTS 6-21-13MONITORING 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: #7781 Fastrip #22 (South) Bldg. No.: ___ _
Site Address: 4013 South H Street City: Bakersfield Zip: .::...93.:....3:.....:0:.....:4 __ _
Facility Contact Person: Omero Garcia Contact Phone No.: (661) 393-7000
Make/Model of Monitoring System: Veeder-Root TLS-350 Date ofTesting/Servicing: 6/21/2013
B. Inventory of Equipment Tested/Certified
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Tank 10: 12000 gal. Regular 1 Tank 10: 12000 gal. Regular 2
181 In-Tank Gauging Probe. Model: 847390-107 181 In-Tank Gauging Probe. Model: 847390-107
181 Annular Space or Vault Sensor. Model: 794390-420 181 Annular Sp.1ce or Vault SerL~r. Model: 794390-420
181 Piping Sump I Trench Senso"s). Model: 794380-208 181 Piping Sump I Trench Senso"s). Model: 794380-208
0 Fill Sump Sen.so"s). Model: 0 Fill Sump Sen.sor(s). Model:
181 Mechanical Line Leak Detector. Model: FX1V 0 Mechanical Line Leak Detector. Model: N/A
0 Electronic Line Leak Detector. Model: 0 Electronic l.ine Leak Detector. Model:
181 Tank Overfillllligh-Lcvel Sensor. Model: 847390-107 181 Tank Overlill/lligh-Level 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. Super Tank 10: 12000 gal. Diesel
181 In-Tank Gauging Probe. Model: 847390-107 181 In-Tank Gauging Probe. Model: 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 /Trench Sensor(s). Model: 794380-208
0 Fill Sump Scnsor(s). Model: 0 Fill Sump Senso"s). Model:
181 Mechanical Line Leak Detector. Model: FX1V 181 Mechanical Line Leak Detector. Model: FX1DV
0 Electronic Line Leak Detector. Model: 0 Electronic Line l.eak Detector. Model:
181 Tank Overfill/ High-Level Sensor. Model: 847390-107 181 Tank Overfill I II igh-Level Sensor. Model: 847390-107
0 Other (specify equipment type and model in Section Eon Page 2). 0 Othcr(spccifY equipment type and model in Section Eon Page 2).
Dispenser 10: 1&2 Dispenser 10: 3 & 4
181 Dispenser Containment Sensor(s). Model: 794380-208 181 Dispenser Containment Scnsor(s). Model: 794380-208
181 Shear Valvc(s). 181 Shear Valvc(s).
0 Dispenser Containment Float(s) and Chain(s). 0 Dispenser Containment Float(s) and Chain(s).
Dispenser 10: 5 & 6 Dispenser 10: 7 & 8
181 Dispenser Containment Senso"s). Model: 794380-208 181 Dispenser Containment Scnsor(s). Model: 794380-208
181 Shear Valvc(s). 181 Shear Valvc(s).
0 Dispenser Containment Float(s) and Chain(s). 0 Dispenser Containment Float(s) and Chain(s).
Dispenser ID: Dispenser 10:
0 Dispenser Containment Sensor(s). Model: 0 Dispenser Containment Scnso"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 -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): I2J System set-up I2J Alarm history report
Technician Name Kristoeher Karns
Certification No.: B341 06 ~--~---------------------------Testing Company Name: Confidence UST Services, Inc.
Site Address: 4013 South H Street, Bakersfield, CA 93304
Page 1
Signature: b£~
License. No.: 804904 ~~~~------------------------Phone No.: (800) 339-9930
Date of Testing/Servicing: 6/21/2013
of 3
Monitoring System Certification
D. Results of Testing/Servicing
Software Version Installed: .....::.3.::.2::..;9.:..:0.::.2 _____________ _
c he foil kf ."'" ...
18:1 Yes 0 No* Is the audible alarm operational?
181 Yes 0 No* Is the visual alarm operational?
181 Yes 0 No* Were all sensors visually inspected, functionally tested, and confirmed operational?
18:1 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 arc relayed to a remote monitoring station, is all communications equipment (e.g., modem)
18:1 N/A operational?
18:1 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) 18:1 Sumpffrench Sensors; 18:1 Dispenser Containment Sensors.
Did you confim1 positive shut-down due to leaks and sensor failure/disconnection? 18:1 Yes; 0 No.
0 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? %
0 Yes* 18:1 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.
0 Yes* 0 No Was liquid found inside any secondary containment systems designed as dry systems? (Check all !hat apply)
0 Product; 0 Water. If yes, describe causes in Section E, below.
18:1 Yes 0 No* Was monitoring system set-up reviewed to ensure proper settings? Attach set up reports, if applicable
181 Yes 0 No* Is all monitoring equipment opel"ational per manufacturer's specifications?
* In Section E below, describe how and when these deficiencies were or will be corrected.
E. Comments: This was an electronic Monitoring Certification. and only testing the functionality of the Veeder Root
Sensors after the store was re-piped. This was required by the Bakersfield Fire Department with inspector
Ernie Medina.
Page 2 of 3
Monitoring System Certification
F. In-Tank Gauging I SIR Equipment: ~ 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:
~Yes 0 No* Has all input wiring been inspected for proper entry and termination, including testing for ground fuults?
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?
0 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 ifLLDs are not installed.
c he 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 LLDs confirmed operational and accurate within regulatory requirements?
181 Yes 0 No* Was the testing apparatus properly calibrated?
~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 offifthc LLD detects a leak?
181 N/A
0 Yes 0 No* For electronic LLDs, does the turbine automatically shut off if any portion of the monitoring system is disabled
181 N/A or disconnected?
0 Yes 0 No* For electronic LLDs, does the turbine automatically shut off if any portion of the monitoring system
181 N/A malfunctions or fails a test?
0 Yes 0 No* For electronic LLDs, have all accessible wiring connections been visually inspected?
181 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
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~fiDE'+. CJo C\ ~usT: Job Order /Invoice #:
J>o=r o 9/1-
~
Name:
Street:
City:
.,. ~-)'liuc't\0
"SUlLO WITH CONFIDENCE•
Lic.970703
+~-s~ ~teE •
"COMPLIANCE WITH CONFIDENCE•
Lic.804904
Toll Free#: 1-800-339-9930
Confidence UST
16250 Meacham Road
Bakersfield CA 93314
Terms: £(£u{C.{)t...J,c.. rYIDN f'lo2.ov6-ua:r.
Date Called Time G--~ ,-,~ C; . .?o ill-11'-1
Site Name: FA~e , (:::> ~-=r,c I
Street: 4D/(, SDi 1 1"-H ././. 5:--r~-r
City: ~ •<:Pt.e:Lb State: ( ,;:)
Store No:
Descriotion of work oerformed: -;+: ~I?FO~¥V'-£-/) '/')IIJ ok'-.£L ...-A t:.-WU)A r Ti'J£uU/';-
Zip: q s>..?ot
u-~-r
--n; s.:l",).,.J ;.. ..t:} ( ( Ltt;?vt'1':,. "5:CJV. (' D£S /.IJ l lt-1 iN )j>fi L.Tot:> -1£.12vt/ I£ Mt:=hJut.Jt4
/)If /i;s::Tf ;)A<:'<€/) llJtJ ;;;~a -rS P,., ,')/.Aefir\
I
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TRAVEL and LABOR (0.5 Hour Minimum Labor Charge) OVERTIME (5:00 PM ·7:00AM)
Date I Technician(s) Name Start End Total OT Start OTEnd OTTotal
.b~f-151 --t-tPtS. ~e?#$ Travel
labor
Travel
Date I Technician(s) Name start End Total OT Start OTEnd OTTotal
I Travel
labor
Travel
Date I Technician(s) Name Start End Total OT Start OTEnd OTTotal
I Travel
labor
Travel
SUPPLIES-MATERIALS-RENTALS Check One
aty. I UST Parts Site Parts
I l
COMMENTS
Store Employee Print Name:
Date
-9 r-8
SITE -CANARY