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Home My WebLink About2012 RESULTSMONITORING SYSTEM CERTIFICATION '14 34 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 j This form must be used to document testing and servicing of monitoring equipment. A seoarate certification or report must be prepared for each monitorine 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: A -ONE FOOD STORE Bldg. No.: Site Address: 1200 H STREET City: BAKERSFIELD Zip: 93301 Facility Contact Person: BOBBY Contact Phone No.: (661) 324 -4138 Make/Model of Monitoring System: TLS�300 Date of Testing/Servicing: 5/9/2012 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate soecific equipment inspected/serviced: Tank ID: UNL87 (SPLIT) Tank ID: PREM91 (SPLIT) ® In -Tank Gauging Probe. Model: MAG ® In -Tank Gauging Probe. Model: MAG ® Annular Space or Vault Sensor. Model: 420 (SPLIT) ® Annular Space or Vault Sensor. Model: 420 (SPLIT) ® Piping Sump / Trench Sensor(s). Model: 208 ® Piping Sump / Trench Sensor(s). Model: 208 ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ® Mechanical Line Leak Detector. Model: RED JACKET ® Mechanical Line Leak Detector. Model: RED JACKET ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other (specify equipment We and model in Section E on Page 2). ❑ Other (specify equipment type and model in Section E on Page 2). Tank ID: Tank ID: ❑ In -Tank Gauging Probe. Model: ❑ In -Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Annular Space or Vault Sensor, Model: ❑ Piping Sump / Trench Sensor(s). Model: ❑ Piping Sump / Trench Sensor(s). Model: ❑ Fill Sump Scnsor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other (specify equipment type and model in Section E on Page 2). ❑ Other (specify equipment type and model in Section E on Page 2). Dispenser ID: 112 Dispenser ID: 314 ❑ Dispenser Containment Sensor(s). Model: 208 ® Dispenser Containment Sensor(s). Model: 208 ® Shear Valve(s). ® Shear Valve(s). ❑ Dispenser Containment Floats) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). Dispenser ID: 516 Dispenser ID: 718 ® Dispenser Containment Sensor(s). Model: 406 ® Dispenser Containment Sensor(s). Model: 406 ® Shear Valve(s). ® Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑ 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 erating such reports, I have also attached a copy of the report-, (check all that apply): ® System set -up ® Alarm hilt report Technician Name (print): RICH PHILLIPS Signature: Certification No.: A2908411035169 -UT License. No.: C61 I D40 809850 Testing Company Name: RICH ENVIRONMENTAL Phone No.: (661) 392 -8687 Testing Company Address: 5643 BROOKS CT. BAKERSFIELD, CA 93308 Date of Testing/Servicing: 519/2012 Page 1 of 5 UN -036 -1/4 www.unidoes.org Rev. 01/17/08 Monitoring System Certification D. Results of Testing/Servicing Software Version Installed: 419.05 Complete the following checklist: E Yes p No* Is the audible alarm operational? 6a Yes I 11 No* Is the visual alarm operational? 114369 t • Yes ❑ No* Were all sensors visually inspected, functionally tested, and confirmed operational? • Yes ❑ No* Were all sensors installed at lowest point of secondary containment and positioned so that other equipment will not interfere with their proper operation? ❑ Yes ❑ No* If alarms are relayed to a remote monitoring station, is all communications equipment (e.g., modem) ® N/A operational? ® Yes ❑ No* For pressurized piping systems, does the turbine automatically shut down if the piping secondary containment ❑ 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) E Sump/Trench Sensors; E Dispenser Containment Sensors. Did you confirm positive shut -down due to leaks and sensor failure /disconnection? ® Yes; ❑ No. ❑ Yes ❑ No* 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 visible and audible at the tank fill point(s) and operating properly? If so, at what percent of tank capacity does the alarm trigger? % ❑ Yes* ® 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. ❑ Yes* E No Was liquid found inside any secondary containment systems designed as dry systems? (Check all that apply) ❑ Product; ❑ Water. If yes, describe causes in Section E, below. E Yes ❑ No* Was monitoring system set -up reviewed to ensure proper settings? Attach set up reports, if applicable E Yes ❑ 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: DISP #1/2 & #3/4 ARE POS. DISP #5/6 &#7/8 ARE STAND ALONE SENSORS Page 2 of 5 UN -036 - 214 www.unidocs.org Rev. 01/17/08 Monitoring System Certification F. In -Tank Gauging / SIR Equipment: Y636� ® Check this box if tank gauging is used only for inventory control. ❑ 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 ❑ No* Has all input wiring been inspected for proper entry and termination, including testing for ground faults? ❑ Yes ❑ No* Were all tank gauging probes visually inspected for damage and residue buildup? ❑ Yes ❑ No* Was accuracy of system product level readings tested? • Yes ❑ No* Was accuracy of system water level readings tested? • Yes ❑ No* Were all probes reinstalled properly? ❑ Yes ❑ No* Were all items on the equipment manufacturer's maintenance checklist completed? * In Section H, below, describe how and when these deficiencies were or will be corrected. G. Line Leak Detectors (LLD): Comnlete the followinLy checklist: ❑ Check this box if LLDs are not installed. ® Yes ❑ No* For equipment start-up or annual equipment certification, was a leak simulated to verify LLD performance? ❑ N/A (Check all that apply) Simulated leak rate: ® 3 g.p.h.; [10. 1 g.p.h ; ❑ 0.2 g.p.h. ® Yes ❑ No* Were all LLDs confirmed operational and accurate within regulatory requirements? ® Yes ❑ No* Was the testing apparatus properly calibrated? ® Yes ❑ No* For mechanical LLDs, does the LLD restrict product flow if it detects a leak? ❑ N/A ❑ Yes ❑ No* For electronic LLDs, does the turbine automatically shut off if the LLD detects a leak? ® N/A ❑ Yes ❑ No* For electronic LLDs, does the turbine automatically shut off if any portion of the monitoring system is disabled ® N/A or disconnected? ❑ Yes ❑ No* For electronic LLDs, does the turbine automatically shut off if any portion of the monitoring system malfunctions ® N/A or fails a test? ❑ Yes ❑ No* For electronic LLDs, have all accessible wiring connections been visually inspected? ® N/A ® Yes ❑ No* Were all items on the equipment manufacturer's maintenance checklist completed? * In Section H, below, describe how and when these deficiencies were or will be corrected. 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If you already have a disgram that shows all required kam ation, you may include it, rather than this page, with your Momtorhs System Catfic a im On your site plan, show the general l w= of tanks and piping. Cleo* identify locations of ft hollowing equipment, ifhwWled: mov tO gg systerit.coni'tol panels; sons=- lucnitoring tank aaanlar sumps,'dispeaser paas,: spill =miners, or odw secondary immft areas; medauical or el=l -o uc tine leak doowtm; ama in- tank - liquid level probes (if used for leak datoWw). In dw spaoa p xMdcd, note the dow Viis Site Plan was: prapwv& Page L of S 4sM RICH ENVIRONMENTAL 5643 BROOKS CT. BAKERSFIELD, CA. 93308 OFFICE (661)392 -8687 FAX (661)392 -0621 PRODUCT LINE LEAK DETECTOR TEST WORK SHEET W /0#: FACILITY NAME: A -ONE FOOD STORE FACILITY ADDRESS: 1200 H STREET, BAKERSFIELD PRODUCT LINE TYPE: PRESSURE y6368 PRODUCT LEAK DETECTOR TYPE TEST TRIP PASS BELOW P.S.I. OR SERIAL NUMBER 3 G.P.H. FAIL 87 L/D TYPE: RED JACKET YES 9 PASS SERIAL # 7921 91 L/D TYPE: RED JACKET YES 10 PASS SERIAL # 7915 L/D TYPE: YES PASS SERIAL # NO FAIL L/D TYPE: YES PASS SERIAL # NO FAII. I CERTIFY THE ABOVE TESTS WERE CONDUCTED ON THIS DATE ACCORDING TO RED JACKET PUMPS FIELD TEST APPARATUS TESTING PROCEDURE AND LIMITATIONS. THE MECHANICAL LEAK DETECTOR TEST PASS / FAIL IS DETERMINED BY USING A LOW FLOW THRESHOLD TRIP RATE OF 3 GALLONS PER HOUR OR LESS AT 10 P.S.I. I ACKNOWLEDGE THAT ALL DATA COLLECTED IS TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE. TECHNICIAN RICH PH1196PS SIGNATURE: DATE: 5-9 -12 7&W SWRCB, January 2006 Spill Bucket Testing Report Form This form is intended for use by contractors performing annual testing of UST spill containment structures. The completed form and printouts from tests (f applicable), should be provided to the facility owner /operator for submittal to the local regulatory agency. 1. FACILITY INFORMATION Facility Name: A -ONE FOOD STORE Date of Testing: 5/9/12 Facility Address: 1200 H STREET, BAKERSFIELD Facility Contact: BOBBY Phone: 661- 324 -4138 Date Local Agency Was Notified of Testing : 3/28/ 12 Name of Local Agency Inspector (fpresent during testing): ESTHER DURAN 2. TESTING CONTRACTOR INFORMATION Company Name: RICH ENVIRONMENTAL Technician Conducting Test: RICH PHILLIPS Credentials': ❑ CSLB Contractor X ICC Service Tech. ❑ SWRCB Tank Tester ❑ Other (Specify) License Number(s): 1035169 -UT 3. SPILL BUCKET TESTING INFORMATION Test Method Used: X Hydrostatic ❑ Vacuum ❑ Other Test Equipment Used: VISUAL Equipment Resolution: 0 Identify Spill Bucket (By Tank Number, Stored Product, etc t 87 FILL z 91 FILL 3 4 Bucket Installation Type: X Direct Bury ❑ Contained in Sump X Direct Bury ❑ Contained in Sump ❑ Direct Bury ❑ Contained in Sump ❑ Direct Bury ❑ Contained in Sum Bucket Diameter: 12" 12" Bucket Depth: 16" 16" Wait time between applying vacuum/water and start of test: 30 MIN 30 MIN Test Start Time (Tj): 1:00 1:00 Initial Reading (IQ: 10" 10" Test End Time (TF): 2:00 2:00 Final Reading (RF): 10" 10" Test Duration (TF — Tj): 1 -HOUR 1 -HOUR Change in Reading (RF -Rj): 0 0 Pass/Fail Threshold or Criteria: +/-0.00 +/-0.00 Test Result: X Pass ❑ Fail X Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail Comments — (include information on repairs made prior to testing, and recommended follow -up for failed tests) CERTIFICATION OF TECHNIC RESPONSIBLE FOR CONDUCTING THIS TESTING 1 hereby certify that all the information conta' d in this report is true, accurate, and in full compliance with legal requirements. Technician's Signature: Date: 5/9/12 ' State laws and regulations do not currently require testing to be performed by a qualified contractor. However, local requirements may be more stringent. SOFTWARE REVISION LEVEL VERSION 419.05 SOFTWARE# 346419 -100 -F CREATED - 00.02.25.12.40 S- MODULE# 330161 -001 -a SYSTEM FEATURES: PERIODIC IN-TANK TESTS ANNUAL IN -TANK TESTS A -ONE STORE 1200 H ST BAKERSFIELD CA 93301 661- 324 -4138 MAY 9, 2012 2:57 PM SYSTEM STATUS REPORT - ALL FUNCTIONS NORMAL SYSTEM SETUP MAY 9, 2012 2:58 PM SYSTEM UNITS U.S. SYSTEM LANGUAGE ENGLISH SYSTEM DATE /TIME FORMAT MON DD YYYY HH:MM:SS xM A -ONE STORE 1200 H ST BAKI±RSFIELD CA 93301 661324 -4138 SHIFT TIME 1 : 545 AM SHIFT TIME 2 : DISABLED SHIFT TIM£ 3 : DISABLED SHIFT TIME 4 : DISABLED TANK PER TST NEEDED WRN DISABLED TANK ANN TST NEEDED WRN DISABLED LINE PER TST NEEDED WRN DISABLED LINE ANN TST NEEDED WRN DISABLED PRINT TC VOLUMES ENABLED 1 GI'It' 4 +Jrttlr l jm L 1 V IV VALUE (DEG F ): •60.0 STICK HEIGHT OFFSET DISABLED H- PROTOCOL DATA FORMAT HEIGHT DAYLIGHT SAVING TIME ENABLED START DATE APR WEEK 1 SUN START TIME 2:00 AM END DATE OCT WEEK 6 SUN END TIME 2:00 AM RE- DIRECT LOCAL PRINTOUT DISABLED EURO PROTOCOL PREFIX S SYSTEM SECURITY CODE : 000000 COMMUNICATIONS SETUP PORT SETTINGS: COMM BOARD 2 (RS -232) BAUD RATE 1200 PARITY ODD STOP BIT 1 STOP DATA LENGTH: 7 DATA 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 START DISABLED AUTO DELIVERY END DISABLED AUTO EXTERNAL INPUT ON DISABLED AUTO EXTERNAL INPUT OFF DISABLED AUTO SENSOR FUEL ALARM DISABLED AUTO SENSOR WATER ALARM DISABLED AUTO SENSOR OUT ALARM DISABLED RS -232 SECURITY CODE . XXXXXX RS -232 END OF MESSAGE DISABLED IN -TANK SETUP T I:REG UNL PRODUCT CODE 1 THERMAL COEFF :.000700 TANK DIAMETER 128.00 TANK PROFILE 1 PT FULL VOL 15055 FLOAT SIZE: 4.0 IN. 8496 WATER WARNING 2.0 HIGH WATER LIMIT: 3.0 MAX OR LABEL VOL: 15055 OVERFILL LIMIT 90% 13549 HIGH PRODUCT 95% 14302 DELIVERY LIMIT 9% 1500 LOW PRODUCT 500 LEAK ALARM LIMIT: 99 SUDDEN LOSS LIMIT: 50 TANK TILT 0.00 MANIFOLDED TANKS T#: NONE LEAK MIN PERIODIC: 9% 1500 LEAK MIN ANNUAL : 9% 1500 PERIODIC TEST TYPE STANDARD ANI4UAL TEST FAIL ALARM DISABLED PERIODIC TEST FAIL ALARM DISABLED GROSS TEST FAIL ALARM DISABLED ANN TEST AVERAGING: OFF PER TEST AVERAGING: OFF TANK TEST NOTIFY: OFF TNK TST SIPHON BREAK:OFF DELIVETi'Y DELAY : 15 MIN � /63d� T.,2:PREMIUM PRODUCT CODE 2 SENSOR SETUP LIQUID S - - - - / ALARM HISTORY REPORT 7(p 36 THERMAL COEFF :.000700 - - - - ' TANK DIAMETER 128.00 L 1:DISP 1 -2 ' ---- SENSOR ALARM - - - -- TANK PROFILE l PT FULL VOL 7026 TRI-STATE L I:DISP 1 -2 DISPENSER PAM FUEL ALARM FLOAT SIZE: 4.0 IN. 8496 MAY 9, 2012 1:21 PM WATER WARNING 2.0 L 2:DISP 3 -4 TRI -STATE (SINGLE FLOAT) SENSOR OUT ALARM MAY 9, 2012 1:13 PM HIGH WATER LIMIT: 3.0 CATEGORY : DISPENSER PAN SENSOR OUT ALARM MAX OR LABEL VOL: 7026 APR 18. 2011 10:36 AM 20 OVERFILL LIMIT 90i 6323 HIGH PRODUCs.T 954 6674 L 3:87 STP NORMALLY CLOSED _ ALARM HISTORY REPORT DELIVERY LIMIT 9i : STP SUMP 700 ----- SENSOR ALARM -- L 1:DISP 1 -2 -- LOW PRODUCT 500 LEAK. ALARM LIMIT: 99 L 4:92 STP TRI -STATE (SINGLE FLOAT) DISPENSER PAN FUEL ALARM SUDDEN LOSS LIMIT: 50 CATEGORY : STP SUMP MAY 9. 2012 1:21 PM TANK TILT 0.00 SENSOR OUT ALARM TANKS L 5:ANNULAR MAY 9, 2012 1:13 PM TO: N TO: NONE NORMALLY CLOSED CATEGORY ANNULAR SPACE SENSOR OUT ALARM APR 18, 2011 10:36 AM LEAK MIN PERIODIC: wo 700 -- LEAK MIN ANNUAL 990 - .1 REPOT OR 700 �,PRM �Als 0J, es OR PERIODIC TEST TYPE -' "� 8" gTP STANDARD 1 ANNUAL TEST' FAIL F� L 9LP al3 ALARM DISABLED EXTERNAL INPUT SETUP ` AL 2ti 1 . p11 PERIODIC TEST FAIL - ` - - - - - - - NONE EL ALARM DISABLED p1A`I pp1 12 AS GROSS TEST FAIL ppR A�2 ALARM DISABLED AIVN TEST AVERAGING^: OFF PER TEST AVERAGING: OFF ALARM HISTORY REPORT TANK TEST NOTIFY: OFF -- SENSOR ALARM - - - -- L 4:92 STP TNK TST SIPHON BREAK:OFF STP SUMP FUEL ALARM DELIVERY DELAY :.15 MIN OUTPUT RELAY SETUP - - MAY 9, 2012 1:15 PM l _ SENSOR OUT ALARM R 1:87 MAY 9. 2012 1:13 PM TYPE: STANDARD FUEL ALARM NORMALLY CLOSED FEB 16. 2012 8:52 PM - NO ALARM ASSIGNMENTS R 2:92 ALARM HISTORY SPORT ' TYPE: LEAK TEST METHOD STANDARD - - - -- SENSOR ALARM - -_ -- L 5:ANNULAR _ - - _ - - - _ - - NORMALLY CLOSED ANNULAR TEST ON DATE : ALL TANK SPACE FUEL ALARM APR 25, 2001 START TIME : 2:30 AM LIQUID SENSOR ALMS MAY 9, 2012 1:.23 PM TEST RATE :0.20 GAL /HR ALL:FUEL ALARM FUEL ALARM DURATION 2 HOURS MAY 9•'2012 1:13 pM FUEL ALARM LEAK TEST REPORT FORMAT APR 18. 2011 10:36 AM ENHANCED MONITOR CERT. FAILURE REPORT SITE NAME : A -ONE FOOD STORE DATE: CITY: BAKERSFIELD SIGNATURE: ' THE FOLLOWING COMPONENTS WERE REPLACED O COMPLETE TESTING. REPAIRS: li�VJLe LABOR: 1104 PARTS INTALLED : NAME: TITLE: SIGNATURE: THE ABOVE NAMED PERSON TAKES FULL RESPONSIBILITY OF NOTIFYING THE APPROPRIATE PARTY TO HAVE CORRECTIVE ACTION TAKEN TO REPAIR THE ABOVE LISTED PROBLEMS AND NOTIFYING RICH ENVIRONMENTAL FOR ANY NEEDED RETESTING. THIS ALSO RELEASES RICH ENVIRONMENTAL OF ANY FINES OR PENALTIES OCCURING FROM NON - COMPLIANCE. A COPY OF THIS DOCUMENT HAS BEEN LEFT ON -SITE FOR YOUR CONVIENENCE.