HomeMy WebLinkAboutFMC 2013MONITORING SYSTEM CERTIFICATION
For Use By All Jurisdictions Within the State of California
Authority Cited: Chapter 6. 7, 1/ea/th 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. I\ separate certification or report must be prepared for each
monitoring system control panel by the technician who performs the work. I\ 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: Samco Food Store #2 Bldg. No.: ____ _
Site Address: 3300 White La ne City: Bakersfie ld, CA Zip: 93309 .:....;;....;...;;...:;_ __ _
Facility Contact Person: Sam J oud a I Sam J r. Contact Phone No.: (661) 333-0000/472-9090
Make/Model of Monitoring System: ...:V...:e...:e...:d...:e..;..r-..:.R.:.:o:...:o:...:t:....:T:....:L::..S:......:.3..::.5..:.0 _________ Date of Testing/Servicing: 12/9/2013
B. Inventory of Equipment Tested/Certified
Check the appropriate boxes to indicate specific equipment inspected/serviced:
Tank 10: 12,000 gal. Regular Tank 10: 12,000 gal. Su~er
1811n-Tank Gauging Probe. Model: 847390-107 1811n· 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 Scnsor(s). Model: 794380-208 181 Piping Sump I Trench Sensor(s). Model: 794380-208
181 Fill Sump Sensor(s). Model: 794380-208 181 Fill Sump Scnsor(s). Model: 794380-208
181 Mechanical Line Leak Detector. Model: FX-1V 181 Mechanical Line Leak Detector. Model: FX-1V
0 Electronic Line Leak Detector. Model: 0 Electronic Line Leak Detector. Model:
181 Tank Overfill I lligh-L..cvcl Sensor. Model: 847390-107 181 Tank Overfill I lligh-l.cvcl 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: Tank ID:
0 In-Tank Gauging Probe. Model: 0 In-Tank Gauging Probe. Model:
0 Annular Space or Vault Sensor. Model: 0 Annular Space or Vaull Sensor. Model:
0 Piping Sump I Trench Sensor(s). Model: 0 Piping Sump I Trench Sensor(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 lligh-Level Sensor. Model: 0 Tank Overfill I lligh-L..cvel Sensor. Model:
0 Other (specify equipment t)pe and model in Secuon Eon Page 2). 0 Other (specify equipment type and model in Section Eon Page 2).
Dispenser ID: 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 Vnlve(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 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 TD: 9 & 10 Dispenser 10: 11 & 12
181 Dispenser Containment Scnsor(s). Model: 794380-208 181 Dispenser Containment Sensor(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). . . •lfthe facility contains more tanks or dispensers. copy thts form. Include mformauon for every tank and dtspenscr 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
ott.chod • <OPY orth• "poet; (ch"k all lf'"tapply)' 121 Syste m set-up 121 A)a;:.!';s~epo't
Technician Name (print): Bradley Seykora Stgnature: ....;~~2:::::::=:~::=~=======-----
Certification No.: B40738 License. ~_.::.80=..4..:..:9:..:0:....:4:.__ ___________ _
Testing Company Name: Confid ence UST Services Phone No.: ~(8::..:0:..:0:...~.)_:3:..:3:...:9:....-9::..:9::..:3:...:0:...._ ____ _
Site Address: 3300 W h ite La ne, B akersfie ld, CA 93309 Date ofTesting/Servicing: 12/9/2013
Page 1 of 3
Monitoring System Certification
D. Results of Testing/Servicing
Software Version Installed: 329.00 ~~~----------------------------
c omplete the following checkJist:
181 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?
181 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* Tf alanns are relayed to a remote monitoring station, is all communications equipment (e.g., modem)
181 N/A operational?
181 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, fai Is to operate, or is electrically disconnected? If yes: which sensors initiate
positive shut-down? (Check all that apply) 181 Sump/Trench Sensors; 181 Dispenser Containment Sensors.
Did you confirm positive shut-down due to leaks and sensor failure/disconnection? 181 Yes; 0 No.
181 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%
181 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.
181 Yes* 0 No Was liquid found inside any secondary containment systems designed as dry systems? (Check all that apply)
0 Product; 181 Water. If yes, describe causes in Section E, below.
181 Yes 0 No* Was monitoring system set-up reviewed to ensure proper settings? Attach set up reports, if applicable
181 Yes 0 No* Ts 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: The 91 LLD was replaced during testing.
Page 2 of 3
Monito ring 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 equ ipment is used to perform leak detection monitoring.
Complete the following checkl ist:
181 Yes 0 No* Has all input wiring been inspected for proper entry and tem1ination, 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, descnbe how and when these defic•enc1es were or w1ll be corrected.
G. Line Leak Detectors (LLD): 0 Check this box if LLDs are not installed.
c omplcte the following checklist:
181 Yes 0 No* For equipment start-up or annual equipment certification, was a leak simulated to verifY LLD performance?
0 N/A (Check a// 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 ca librated?
181 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?
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 malfunctions
181 N/A or fa ils 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, desc n be how and when these defic•enc1es were or will be corrected.
H. Comments: The origiRal LLD oJ:J the 91 failed to catch a 3 GPH leak@ 10 PSI aRd-was replaced \Alith a ne\Al Red
lacket EX-1\/, the new LLD was tested and confirmed operationaaJ-<1 aa~ftme~rJiunsSlt:aa,u;llaa~t"i( JLl.--------------
Page 3 of 3
Lea k Detector Test Results Sheet
Cust omer Address: Work Order: 31757 Site Address:
Samco Food store, Inc.
3817 Wilson Road, Suit B
Bakersfield, CA 93309
Test Date: 12/9/2013 Samco Food Store #2
3300 White La ne
Bakersfield, CA 93309
Site Contact: Sam Jouda Phone: 661-399-3866
Technician: Bradley Seykora Phone: 800-339-9930 ICC No.: 8111231
Product Type LLD Type Model
Regular UNL Mechanical FX1V
Premium UNL Mechanical FX1V
Technician Name: ~
Signature:
/
Serial No. Check
Valve
Holding
Pressure
N/A 20 PSI
N/A 21 PSI
Technician No.:
-oate:
Bleed Leak
Off ML. Rate
Tested:
95 ml 3gph@
10 psi
115 ml 3gph@
10 psi
3gph@
10 psi
3 gph@
10 psi
3 gph@
10 psi
3 gph@
10 psi
3gph@
10 psi
3gph@
10 psi
8111231
12/9/2013
Pass/Fail
Pass
Pass
BIG COUtlfRY CHEVROtl
3300 WIIITE Ltl.
BAXERSFIELD.CA 93309
661-827 0487
DEC 9. 2013 9:18 N1
SYSTEM STATUS REPORT
I-ILL FUNCTIONS NORMAL
I tlVEtlTORY REPORT
T I :SIJPREI1
VOLU1E • 7763 GALS
ULLAGE • 4237 GALS
9W. ULLAGE• 3037 GALS
TC VOLU1E • 7826 GALS
liEIGHT • 59.18 ltlCHES
WATER VOL • 0 GALS
WATER • 0.00 ltiCHES
TEMP • 48.3 DEC F
T 2:1JtlLEADED
VOLU'1E • 7760 GALS
ULLAGE • 4240 GALS
90Y. ULLAGE• 3040 GALS
TC VOLUME • 7845 GALS
HEIGHT • 59.16 INCHES
WATER VOL • I 8 GAUl
WATER • 0.91 lt~HES
TEMP • 44.3 DEC F
SOF'TWARE REVISI Otl LEVEL
VERSION 329,00
SOFTWAREU 346329-100-A CREATED-08.10.09.17.08
S-HODIJLEU 330160-004-c
SVSTEI1 FEATURES:
PERIODIC lfl-1'fltll: TESTS
AtiiiUAL W-TANI: TESTS
ISO
SYSTEM SETUP
DEC 9. 2013 9:18 A/'1
SYSTEM UtllTS u.s.
SYSTEM LAtl\'lUACE
EIIGLISH
S'/STEM MTE/TIHE FORMAT NOtl DD YVVV HII:MH:SS :.J1
BIG COUtlfRY CHEVROII
0300 WHITE LN, BA~ERSFIELD.CA 93309 661-827 0487
SHIFT TINE I
SHIFT TIME 2
SHIFT TINE 3
SHIFT TINE 4
DISABLED DISABLED
DISABLED
DISABLED
TANK PER TST tiEEDED WRN
DISABLED TAilK ANti TST NEEDED l4Rtl
DISABLED
LitlE RE-ENABLE METHOD
PASS L INE TEST
LitlE PER 1'ST NEEDED WRN
DISABLED Ll tiE Atltl TST IIEEDED WRtl
DISABLED
PRINT TC V0Lil1ES
ENABLED
TEMP COMPEIISATION
VALUE <DEC F): 60.0
STICY. HEIGHT OFFSET
DISABLED
ULLAGE: 90.~
H-PROTOCOL DATA FORt1AT
HEIGHT
DA\ILIGIIT SAVItiG TINE ENABLED
START DATE
MAR WEE~ 2 SUtl
START TIME
2:00 AM
END DATE
NOV WEE.-SUtl
END TIME
2 :00AM
RE-DI RE<-'T L~AI. PRJNTOtrr f-k~SABJ..ErJ._:.:·-. , _..,._. -~
EURO PROTOCOL PP.EFIX s
SVSTS1 SECURITY CODE : 000000
l~ltlfEI·lAt~E HISTORY
DISABLED
TANI: CHART SECURITY
DISABLED
CUSTOt1 ALARMS
DISABLED
SERVICE NOTICE
DI SABLED
ISO 3166 COUNTRV
CODE:
MASS/DENSI TY DISABLED
COI11UIIICATIONS SETUP
PORT SETTJt:CS:
COHM BOARD : 1 <EDIM >
RS-232 SECURITY
CODE : DISABLED
COMM BOARD : 2 <RS-232)
BAUD RATE : 9600 PARITY : EVEN
STOP BIT : 1 STOP
DATA LENGTH: 7 DATA
RS-232 SECURITY
CODE : DISABLED
COI11 BOARD : 3 <RS-232>
BAUD RATE : 9600
PARITY : NONE
STOP BIT : I STOP
DATA LENGTH: 8 DATA
RS-232 SECURITY
CODE : DISABLED
AUTO TRANSMIT SETTINGS:
AUTO LEAK ALARM LIMIT
DISABLED
AUTO HIGH WATER LIMIT
DISABLED
AUTO OVERFILL LIMIT
DISABLED
AUTO LOW PRODUCT DISABLED
AUTO THEFT LIMIT
DISABLED
AUTO DELIVERY STAP.T
DISABLED
AUTO DELIVERY EtiD
DISABLED
AUTO EXTERNAL lllPUT ON
DISABLED
AUTO EXTERNAL I flPUT Off
DISABLED
AUTO SENSOR FUEL ALARM
DISABLED
AUTO SENSOR WATER ALARM
DISABLED
AUTO SENSOR OUT ALARI'I
DISABLED
RS-232 EtlD OF t1ESSAGE
DISABLED
I U-TAtn: SETUP
T I :SUPREH
PRODUCT CODE
THERI1AL COEFF
TANK DIAMETER
TANK PROFILE
FULL VOL
FLOAT SIZE:
WATER WARNitlG :
HIGH WATER L IMIT:
MAX OR LABEL VOL:
OVERFILL LIMIT : .
HIGH PRO_Dy_CT ___ .:
DELIViERv L JHJT :
I
.000700
96.00 I PT
1:1000
4,0 ltl.
2.0
3,0
12000
9W. 10800
95% 1"1400
10'4
1200
LOW PRODUCT : 1200 LEAl: ALARM LIMIT: 99
SUDDEN LOSS LIMIT: 99
TANl: TILT : 0 .00 PROBE OFFSET 0.00
SIPHON ~lANIFOLDED TANKS
Til! NOtiE
LitlE MANIFOLDED TAtiKS Til: NONE
LEAl: NIN PERIODIC:
LEAK Hill ANtlUAL ;
1 OJ:
1200
I 0!~
1200
PERIODIC TEST 1"/PE
STANDARD
AtliiUAt TEST FAll. ALARM DISABLED
PERIODIC TEST FAIL
. ALARM DI SABLED
GROSS TEST FAIL .. "ALARM D I SABI.ED
A Nil TEST AVERAG ltiG: OFF
PER TEST AVERAGING: OFF
TAIIK TEST NOTI FY: OFF
TNK TST SIPHON BREAI::OFF
DELIVERY DELAY : 1 MIN
PltlP THRESHOLD : 1 0. OOl;
T 2:Utll.EADED
PRODUCT CODE
THERt1AL COEfF
TAIIK DIAMETER
TAIIK PROFILE
FULL VOL
FLOAT SI ZE:
WATER ~IARNltlG :
HIGH WA\ER k~HJT:
NAX OR LABEL VOL: OVERFILL LIMIT :
HIGH PRODUCT
DELIVERY LIMIT
2
.000700
96.00
1 PT
12000
ol.O IN.
2.0
3.0
12000 90~;
10800
95!,
11~00
10'4 1200
LOW PRODUCT : 1200
LEAl: ALARM LII1JT: 99
SUDDEN LOSS LIMIT: 99
TANK TILT : 0.00
PROBE OFFSET : 0.00
SIPHON MAtHFOI.DED TAIIKS
Til: tlONE
LINE NAtUFOLOED TANI:S Til: fiONE
LEAK MIN PERIOD!~:
LEAK Mltl ANNUAL
lOY. 1200
10'4
1200
PERIODIC TEST TYPE
STANDARD
AtltlUAL TEST FAIL ALARM DISABLED
PERIODIC TEST FAIL ALARH DISABLED
GROSS TEST FAIL ALARM DISABLED
AtlN TEST AVERAGING: OFF
PER TEST AVERAGING: OFF
TANK TEST NOTIFY: OFF
TtlK TST SIPHON BREAK:OFF
DELIVERY DELAY : 1 MIN
PUMP THRESHOLD : 10,0W.
LEAl: TEST METHOD
TEST MONTHLY : ALL TANK WE.EK I MOll
START TIME : 2:00 At1
TEST RATE :0.20 GAL.'HR
DURATION : 2 HOURS
TST EARLY STOP:EIIABLED
LEAl: TEST REPORT FORtiAT NORNAL
LIQUID SEIISOR SETUP
L I :OISP 1-2
TRI-STATE <SINGLE FLOAT> CATEGORY : DISPEIISER PAt~
L 2!DI SP 5-6
tl0Rf1Al.LY CLOSED
CATEGORY : DISPENSER PAN
L 3:DISP 3-4
NORMALLY CLOSED
CATEGORY· .; DISPEtiSER PAll
L 4!DISP 7-B
TRI-STATE <SINGLE FLOAT>
CATEGORY : DISPENSER PAll
L s:OISP 9-10
TRI-STATE <SHIGLE FLOAT>
CATEGORY : DISPEtiSER PAN
L 7:DISP 11-12
TRI-STATE <SINGLE FLOAT>
CATEGORY : DISPEtiSER PAll
L 9:67 STP
TRI-STATE <SitiGLE FLOAT>
CATEGORY : STP SUMP
LIO:S7 ANN
TRI-STATE <SitiGLE FLOAT>
CATEGOR\' : AWIULAR SPACE
LII:B7 FILL
TRI-STATE (SitiGLE FLOAT)
CATEGORY : PIPING SlJ1P
Ll2:91 Arm
TRI-STATE <SitlGLE FLOAT>
CATEGORY : ANtlULI\R SPACE
Lt3:91 STP
TRI-STATE <SitiGLE FLOAT>
CATEGORY : STP SUMP
Ll4!91 FILL
TRI-STATE <SHIGLE FLOAT>
CATEGORY : PIPHIG SUMP
OUTPur RELAY SETUP
R I :POSTITIVE SHUT OFF
TYPE:
STAfiDA.RD
NORMAL!.'! CLOSED
TANK 11:
LIOUID SEUSOR ALMS
L I :FUEL ALARM
L 2:FUEL ALARM
L 3:FUEL At..ARH
L 4 :FUEL ALARM
L 5:FUEL ALARM
L 7!FUEL ALARN
L 9 :FUEL ALARM
LI3:FUEL ALARM
L I :SiltiSOR our ALAP.H
L 2:SENSOR Our ALARM
L 3:SEIISOR OUT AU\RM
L 4 :SENSOR OUT ALARM
L 5:SENSOR OUT AU\P.t1
L 7:SEtiSOR OUT AU\P.t1
L 9:SEtiSOR OUT ALARM
LI3:SEIISOR OUT ALARM
L I :SHORT AU\RH
L 2:SHORT ALARII
L 3:SHORT ALARH
L 4 :SHORT AU\PJ1
L S:SHORT ALARM L 7 !SIIORT ALARM
L 9!SHORT AU\RH L13!SIIORT AU\PJ1
lSD SITE AU\Rt1S
lSD GROSS PRES FAIL
lSD DEGRD·PRES F.AIL
lSD VAPOR LEAl: FAIL
lSD VP PRES FAIL
lSD VP STATUS FAIL
lSD HOSE ALARMS
Att:GROSS COLLECT FAIL
ALL:DEGRD COLLECT FAI L
ALL!FLCX.J COLLECT FAIL
R 2!0VERFILL ALARH
T\'PE:
STAUDARD
tiORNALLY OPEII
TANY. P : tiONE
lti-TAtll: ALARMS
ALL:OVERFILL AU\RH
ALL!HIGH PRODUCT ALARM ALL!~IA.'< PRODUCT ALARM
SMARlSEtlSoR SETUP
~l:FHJ-2
CATEGORY AIR FLOW HETEP.
!!I 3:FM 5-6 CATEGORY AIR FLOW METER
!!I 4:Fl1 7-8 CATEGORY AIR FLOW METER
!!1 5:FM 9-10 CATEGORY AIR FLOW METER
s 6:FM 11 -12
CATEGORY AIR FLOW METER
s 7:FM 3-4
CATEGORY AIR FLOW METER
s s:ps 1-2
CATEGORY VAPOR PRESSURE
EVR/JSD SETUP
EVR TYPE: VACUUI1 ASSIST VACUUM ASS IST TYPE HEALY VAC
tlOZZ!.E A/L RANGE
HAX: 1.15 Mltl: 0.95
VAPOR PROCESSOR TYPE UOtlE
ANALYSIS TIMES TIME: 10:00 AM DELAY HltlUTES:
ACCEPT HIOII ORVR: ENABLED
lSD HOSE TABLE 10 FP FL IlL AA RR ------------------------01 33 01 02 01 uu 02 34 02 02 01 uu 03 35 03 02 06 uu 04 00 04 02 06 uu 05 01 05 02 02 uu 06 ll2 06 02 02 uu 07 03 07 02 03 uu 09 04 09 02 03 uu 09 05 09 02 04 uu 10 06 10 02 04 uu 11 07 I I 02 05 uu 12 09 12 02 05 uu
ISO AIRFLOW METER MAP ID SERIAL tH.t1 LABEL ------------------------I 24027 2 25069 3 24030 4 24373 5 25167 6 25054
FH 1-2 FH 5-6 FH 7-9 FH 9-10 FH 11-12 FH 3-4
lSD FUEL \JRADE IIOSE HAP
1 2 3 4 FP 11HH HHH HHH HHH M
00 204 904 304 u u 6 01 205 905 305 u u 2 02 206 906 306 u u 2 03 207 907 307 u u 3 04 208 909 309 u u 3 05 209 909 309 u u 4 06 210 910 310 u u 4 07 211 91 1 311 u u 5 09 212 912 312 u u 5 33 201 901 301 U U I 34 202 902 302 u u 1 35 203 903 303 u u 6
LABEL TABl.E
1: UtiASSICUEO 2: BLEN03 3: REGULAR 4: MID GRADE
5: PREMIUM 6: GOLD 7: BRONZE e: SILVER 9: BLEND2 10: BLEND4
P~ SETUP
f-MC VERSIOU: 01.02
VAPOR PROCESSOR TYPE NOliE
PROCESSOR CONTROL LEVEL: ti014E
ALARM HISTORY REPORT
-----SEtlSOR ALARM -----L 1 :DISP 1-2 DISPEtiSER PAN
SETUP DATA WARN! 00 0\;.,. 9. 2009 8:03 Ali
ALAI<M HISTORY REPORT
-----SEtlSOR ALARI1 -----L 2:DISP 5-6 DISPENSER PAN
FUEL ALARM ocr 9. 20o9 e:os AH
SETUP DATA WARNHlG OCT 9. 2009 e :o3 AM
.,. .
ALARM HISTORY REPORT
-----SENSOR ALARM -----L 3:DISP 3-4 DISPENSER PAN
FUEL ALARM oCT 9. 2oo8 8:os AM
SETUP DATA WARNitlG OCT 9. 2008 8:03 AH
ALARM HISTORY REYORT
-----SEtlSOR ALARM -----L 4!DISP 7-8 DISI'EUSER PAN
SETUP DATA WARtH NG OCT 9. 2008 8:03 AN
ALARH IIISTOR'l RE!iORT
-----SENSOR ALARM -----
L 5:DIS!i 9-10
DISPEt4SER PAri SETUP DATA tJARN!IlG OCT ·9·. ··2008 8 :03 Al1
ALARM HISTORY REPORT
-----SEt4SOR ALARM -----L 7:DISP 11-12 DISPENSER PAN
SETUP DATA WARNING OCT 9. 2008 8:03 AN
ALARM HISTORY REPOR1
-----SEt4SOR ALAAt1 -----L 9!87 STP STP SU'IP SETUP DATA WARN! tiG OCT 9. 2008 8:03 AM
ALARH HISTORY REPORT
-----SE!4SOR ALARM -----1.10!87 ANN
AtHWLAR SPACE
SETUP DATA WARNING OCT 9. 2008 8:03 AM
ALARM HISTORY REPORT
-----SEt4SOR Al.ARH -----1.11 !87 FILL
PIPI NG SUMP SETUP DATA WARNING OCT 9. 2008 8:03 AN
ALARM HISTORY REPORT
-----SENSOR ALARM -----1.12:91 AtlN
ANNULAR SPw;E
SETUP DATA WARtll NG OCT 9. 2008 8:03 AN
M J( ~ )( J( END M " ~ ll ,;,
ALARM HISTOR'l P.EPORT
-----SENSOR ALARM 1.13!91 STP
STP SUHI'
SETUP ()ATfl t.JARtH t.IG
OCT 9. 2008 8:03 AH
ALARM IHSTOR'/ REPORT
-----SElSOR AUiRI1 -----LI4:91 FILL PIPING Sl.t1P
SETUP DATA WARNING OCT 9. 2008 8:03 AN
* * ;o l< )( END l< l< )( It *
BIG COUNTRY CIIEVROtl
3300 WHITE LN. BAKERSFIELD.CA 93309
661-827 0497
DEC 9. 2013 9:21 AH
SYSTEM STATUS P.EPORT
ALL FUNCTIONS NORMAL
.·
-----SENSOR ALARM -----Ll3:91 STP STP SUMP
SEIISOR OUT ALARM DEC 9. 2013 9:38 AH
-----SElSOR ALA'RN -----L 9:87 STP
STP SU1P SElSOR OUT ALARM DEC g. 2013 9:39 AN
-----SENSOR ALARM -----L11 :87 FILL PIPING SUMP SElSOR OUT ALARM DEC 9; 2013. 9:39.AH
-----SEt~OR ALARM -----L12:91 ANt~ ANNULAR SPACE SENSOR OUT ALARM DEC 9. 2013 9:39 AN
-----SEtiSOR ALARM -----L 5:DISP 9-10 DISPENSER PAll SEtSOP. OUT ALAP.H DEC 9. 2013 9:39 AH
-----SEtiSOR ALARM -----LI4:91 FILL PIPING SLtiP SElSOR OUT ALARM DEC 9. 2013 9!39 AM
-----SEUSOR ALARM -----L 7:DISP 11-12 DISPEtiSER PAtl SENSOI< OUT ALARM DEC 9. 2013 9:39 AN
-----SENSOR ALARM -----LJ0:87 Atm ANNULAR SPAI:E SENSOR OUT ALARM DEC 9. 2013 9:39 AN
-----SENSOR ALARM -----L 1 :OISP 1-2 DISPEISER PAll SENSOR OUT ALARM DEC 9. 2013 9:39 AN
-----SElSOR ALARM -----L 3:DISP 3-4 DISPENSER PAN FUEL ALARM DEC 9. 2013 9:39 AM
-----SElSOR OLARM -----1. 4:01SP 7-9 DISPEUSER PAN SENSOR OUT ALARM DEC 9. 2013 9:39 AH
-----SElSOR ALARM -----L 2:01SP 5-6 DISPEIISER,PAU-. -FUEL ALARM DEC 9. 2013 9:39 N1
-----SElSOR ALARH -----L 9:87 STP STPSli1P FUEL AlARM DEC 9. 2013 9:43 AN
-----SEtiSOR EiLARt1 -----L 9:87 STP STPSli1P FUEL A!.EiRt1 DEC 9. 2013 9:44 AM
-----SENSOR ALARM -----L13:St STP·····
STP Slf1P FUEL ALARH DEC 9. 2013 9:45 AN
-----SENSOR ALARM -----1.14:91 FILL PIPING SUMP
FUEL ALARH DEC 9. 2013 9:53 AN
-----SENSOR AI.J11\t1 -----L14:91 FILL PIPING S!R1P FUEL ALARM DEC 9. 2013 9:53 AH
-=----SEIISOP. ALARI1 -----LII :87 FILL PIPING SUMP FUEL ALARM DEC 9. 2013 9:55 AH
-----SENSOR Al.A'RN -----LI0:87 AtlN ANNULAR SPACE FUEL ALARH DEC 9. 2013 9:56 AH
-----SENSOR ALARU -----LI2:91 ANN ANNULAR SPACE FUEL ALARM DEC 9. 2013 10:00 AM
T 2:Utll.EADED ltNENTOP.V INCREASE
I tiC REASE START DEC 9. 2013 9:50 AN
VOLUME HEIGHT WATER
TEMP
• 6546 GI-\LS • 51 .43 ItlCHES .. 0.00 INCHES
• 37.5 DEG F
I NCR EASE EUD DEC 9. 2013 10:01 AH
VOI.li1E HEIGHT WATER TEMP
• 8435 GALS • 63.58 ltiCHES " 0.00 INCHES • 37.6 DEG F
GROSS lt£REASE• 1889 TC tiET INCREASE" 1917
BIG COUilTRV CHEVRON 3300 WHITE W . , BAKERSFIELD.CA 93309 661-827 0487 -· -·. ·-·-·.~ -., DEC 9. 2013 10:02 ~1
SVSTrM STATUS REPORT
ALL FUtiC1'10NS NORMAL
-----SENSOR ALH'RN -----1. I :OISP 1·2 DISPEtSER PAN FUEL ALARH DEC 9. 2013 10:05 AN
-----SEtiSOR ALARM -----
1. I :DISP 1-2 DISPENSER PAN FUEL ALARM DEC 9. 2013 10:14 AH
-----SEISOP. ALARM -----L 3:DISP 3-4 DISPENSER PAN FUEL ALARM DEC 9. 2013 10:16 AH
-----SEt/SOP. ALARM -----1. 3:DISP 3-4 DISPEtlSER PAN FUEL ALARM DEC 9. 2013 10:16 AH
-----SElSOR ALARM -----
1. 2:DISP 5·6 DISPENSER PAN FUEL ALARM DEC 9. 2013 10:18 AM
-----SEtlSOR ALARI1 -----L 4:DISP 7-8 DISPENSER PAll FUEL ALARM DEC 9. 2013 10:19 AM
-----SEIISOR ALARH -----L 5:DISP 9-10 fliSPENSER !'AN FUEL ALARM DEC 9. 2013 10:20 AN
-----SENSOR ALAR11 -----L 7:DtSP 11-12
DISPENSER PAN FUEL ALARM DEC 9. 2013 10:21 AH
----111-TANl: ALARM -----T 2: UNLEADED
OVERFILL ALARM DEC 9. 2013 10:32 AM
----IN-TAN!: ALARM -----T 2:UtH.EADED PROBE OUT DEC 9. 2013 10:32 ~1
----IN-TANK ALAP.tl -----T 2:UNLEADED
LOW TEMP WARtH NG
DEC 9. 2013 10:33 AH
----Ill-TANK ALARM -----T I :SUPREM HIGH PRODUCT ALARM DEC 9. 2013 10:33 AM
---I fl-TAtll: ALARM -----T I :SUPREM !>ROBE OUT
DEC 9. 2013 10:33 N1
T 2:UllLEADED ltiVEIITORY IIICREASE
lllCREASE START DEC 9. 2013 10:31 AM
VOLL\'1E HEICIIT WATER
TEMP
• 8427 GALS
• 63,53 IIICHES .. 0.00 INCHES
a 38.1 DEC.F
INCP.EASE END
DEC 9. 2013 10:34 AH
VOLUME HEIGHT WATER TEMP
.. 11356 GALS
a 66.19 INCHES • 0.00 !fiCHES • 36.3 DEC F
GROSS I IICREASE• 2929 TC NET INCR~SEa 2972
----I N-TAtu: ALARH -----T I :SUPREI'I
It !VALID FUEL LEVEL DEC 9. 2013 10:311 A/'1
----IN-TAN!: ALAP.M -----T I :SUPRE11 LOW PROD~-r ALARM DEC 9. 2013 10:34 AH
----Hl-TANI\ ALARH -----T I :SUPREM DELIVER'/ NEEDED DEC 9. 2013 10:34 ~1
T I :SUI'REM
IIIVEtlTORY I tiC REASE
INCREASE START DEC 9. 2013 10:32 AM
VOLL\'1E
HEIGHT
WATER
TEMP
.. 7763 GALS
" 59.18 WCHES • 0.00 lllCHES
• 43.3 DEC F
INCREASE END DEC 9. 2013 10:36 AM
VOLL\'1E HEIGHT
WATER
TEMP
• 10621 GALS
" 79.46 ltlCHES • 0.00 INCHES • 42.5 DEC F
GROSS IIICREASE• 2658
TC NET INCREASE• 2897
BIG COUtfl'f<\' CHEVROil
3300 WHITE ttl. BAKERSFIELD.CA 93309 661-627 0467
DEC 9. 2013 12:53 PH
SYSTEM STATUS REPORT
ALL FUilCTIOtlS I~RMAL
SWRCB, January 2006
Spill Bucket Testing Report Form
This form is intended for use by contractors peiforming annual testing of UST .spill containment structures. The completedform and
printouts from tests (!f applicable), should be provided to the facility owner/operator for submillalto the local regulatory agency.
1 FACILITY INFORMATION .
Facility Name: SamCo Food Store #2 I Date ofTesting: 12/9/2013
Facility Address: 3300 White Lane, Bakersfield, CA 93309
Facility Contact: Sam Jouda/Sam Jr. I Phone: 661-333-0000/661-472-9090
Date Local Agency Was Notified of Testing: 11 /21/2013
Name of Local Agency Inspector (if present during testing): Ernie Medina
2. TESTING CONTRACTOR INFORMATION
Company Name: Confidence UST Services, Inc.
Technician Conducting Test: Bradley Seykora
Credentials 1: X CSLB Contractor X ICC Service Tech. 0 SWRCB Tank Tester 0 Other (SpecifY)
License Number(s): CSLB #804904 ICC #8 111231-UT
3. SPILL BUCKET TESTING INFORMATION
Test Method Used: X Hydrostatic 0 Vacuum 0 Other
Test Equipment Used: Lake Test Equipment Resolution: 0.0625"
Identify Spill Bucket (By Tank 1 Regular 2 S uper 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: 12.00" 12.00"
Wait time between applying 5 min. 5 min. vacuum/water and start of test:
Test Start Time (T1): 9:30AM 9:30AM
Initial Reading (R1): 9.00" 9.00"
Test End Time (T r ): 10:30 AM 10:30 AM
Final Reading (RF): 9.00" 8.25"
Test Duration (T F-T1): I hour I hour
Change in Reading (RF-R1): 0.00" 0.75"
Pass/Fail Threshold or 0.0625" 0.0625" Criteria:
Test Result: 129 Pass 0 Fail 0 Pass IBl Fail X Pass O Fail 0 Pass 0 Fail
Comments -(include information on repairs made prior to testing, and recommendedfollow-upfor failed tests)
CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING
I hereby certify that all tile information contained in this report is true, accurate, and in full compliance with legal requirements.
Techn;c;an's s;gnat"~ Date' 12/9/2013
1 State laws and regulations do not currently require testing to be performed by a qualified contractor. However, local requirements
may be more stringent.
SWRCB, January 2006
Spill Bucket Testing Report Form
This form is intended for use by contractors 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 the local regulat01y agency.
1 FACILITY INFORMATION .
Facility Name: SamCo Food Store #2 I Date of Testing: 12/9/2013
Facility Address: 3300 White Lane, Bakersfield, CA 93309
Facility Contact: Sam Jouda/Sam Jr. I Phone: 661-333-0000/661-4 72-9090
Date Local Agency Was Notified of Testing: 11/21/2013
Name of Local Agency Inspector (if present during testing): Ernie Medina
2 TESTING CONTRACTOR INFORMATION
Company Name: Confidence UST Services, Inc.
Technician Conducting Test: Bradley Seykora
Credentials 1: X CSLB Contractor X ICC Service Tech. 0 SWRCB Tank Tester 0 Other (Specify)
License Number(s): CSLB #804904 ICC #8111231-UT
3. SPILL BUCKET TESTING INFORMATION
Test Method Used: X Hydrostatic 0 Vacuum 0 Other
Test Equipment Used: Lake Test Equipment Resolution: 0.0625"
Identify Spill Bucket (By Tank 1 Super (Retest) 2 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 Sumo
Bucket Diameter: 12.00"
Bucket Depth: 12.00"
Wait time between applying 5 min. vacuum/water and start of test:
Test Start Time (T1): 1:30PM
Initial Reading (R1): 9.00"
Test End Time (T F): 2:30PM
Final Reading (Rr:): 9.00"
Test Duration (TF-T1): 1 hour
Change in Reading (Rr:-R1): 0.00"
Pass/Fail Threshold or 0.0625" Criteria:
Test Result: l8l Pass 0 Fail 0 Pass 0 Fail 0 Pass 0 Fail 0 Pass 0 Fail
Comments-(include information on repairs made prior to testing, and recommended follow-up for failed tests)
CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING
I hereby certify that all the information contained in this report is true, accurate, and in full compliance with legal requirements.
Technldao 's Slgoawe: ~ Date: 1219/20 t 3 ~ 1 State laws and regulations do not currently require testing to be performed by a qualified contractor. However, local requirements
may be more stringent.
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Name:
Street:
City:
Terms:
13UilD Wllll CONFIDENCE"
Lic.970703
"COMPLIANCE WITH CONFIDENCE"
Lic.804904
Toll Free#: 1-800-339-9930
Confidence UST
16250 Meacham Road
Bakersfield CA 93314
Description of work performed:
Job Order I Invoice #: 317~7
Date Called Time To Whom
Site Name: .5c (-1 <! 0 "Fcc-vi S.Ju r~ :IF 2-
Street: 3 '3 <Jc, '\.-./ \,. . +e. L.::rtv~
City: ~<1'kcr~'.e.l..-f State: e.. rl-Zip: 7:?:ro c;"
Store No: ~L-
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lu-k. v "
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
ll·f-13 1Sr.;-rAv .!t!Y~~ «2. Travel
Labor 3 l-trs.
Travel
Date Technician(s) Name Start End Total OT Start OTEnd OTTotal
rz.f .. 1J BYf(jv J.lu. Travel
Labor 7> l.r.r
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
1 Re.J' ~rk~i-r::k-.1. V Lt.b Jt!
.1... IPL.' 1-+,~~ F, ·tf .>Pt'/1 l3(,(~~ )0
~ IPL,, 'I~ ..J/l~>-F,/t 5'w.'v/e e;c/4)~r-..b
COMMENTS
Store Employee Print Name:
SITF -CANARY