HomeMy WebLinkAbout2011 RESULTSMONITORING SYSTEM CERTIFICATION Fi
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: MIKES FOOD & LIQUOR
Site Address: 2300 PANAMA LANE
Facility Contact Person: MIKE
Make/Model of Monitoring System: INCON TS1000
B. Inventory of Equipment Tested/Certified
Check the aporooriate boxes to indicate specific eauipment insoected/serviced:
Bldg. No.:
City: BAKERSFIELD Zip:
Contact Phone No.: ( )
Date of Testing/Servicing: 11116/2011
Tank ID: UNLEADED
Tank ID: PREM91
Z In -Tank Gauging Probe.
Model: MAG
Z In -Tank Gauging Probe.
Model: MAG
Z Annular Space or Vault Sensor.
Model: LS -3
® Annular Space or Vault Sensor.
Model: LS -3
Z Piping Sump / Trench Sensor(s).
Model: LS -3
Z Piping Sump / Trench Sensor(s).
Model: LS-3
❑ Fill Sump Sensor(s).
Model:
❑ Fill Sump Sensor(s).
Model:
® Mechanical Line Leak Detector.
Model: RED JACKET
Z Mechanical Line Leak Detector.
Model: RED JACKET
❑ Electronic Line Leak Detector.
Model:
❑ Electronic Line Leak Detector.
Model:
Z Tank Overfill / High -Level Sensor.
Model: FLAPPER
® Tank Overfill I High -Level Sensor.
Model: FLAPPER
❑ Other (specify equipment type and model in Section E on Page 2).
❑ Other (specify equipment type and model in Section E on Page 2).
Tank ID: DIESEL
Tank ID:
Z In -Tank Gauging Probe.
Model: MAG
❑ In -Tank Gauging Probe.
Model:
® Annular Space or Vault Sensor.
Model: LS -3
❑ Annular Space or Vault Sensor.
Model:
Z Piping Sump / Trench Sensor(s).
Model: LS-3
❑ Piping Sump / Trench Sensor(s).
Model:
❑ Fill Sump Sensor(s).
Model:
❑ Fill Sump Sensor(s).
Model:
® Mechanical Line Leak Detector.
Model: RED JACKET
❑ Mechanical Line Leak Detector.
Model:
❑ Electronic Line Leak Detector.
Model:
❑ Electronic Line Leak Detector.
Model:
® Tank Overfill / High -Level Sensor.
Model: BALL VALVE
❑ 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: 3/4
® Dispenser Containment Sensor(s).
Model: 406
Z Dispenser Containment Sensor(s).
Model: 406
® Shear Valve(s).
Z Shear Valve(s).
❑ Dispenser Containment Float(s) and Chain(s).
❑ Dispenser Containment Float(s) and Chain(s).
Dispenser ID: 516
Dispenser ID: 718
Z Dispenser Containment Sensor(s).
Model: 406
Z Dispenser Containment Sensor(s).
Model: 406
Z Shear Valve(s).
Z 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 Floats) 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 capab f generating such reports, l have also
attached a copy of the report; (check all that apply): ❑ System set -up [] Alarm o y report
Technician Name (print): RICH PHILLIPS Signature:
Certification No.: A29084/1035169-UT License. No.: 6 640 809850
Testing Company Name: RICH ENVIRONMENTAL Phone No.: (661) 392 -8687
Testing Company Address: 5643 BROOKS CT. BAKERSFIELD, CA 93308 Date of Testing/Servicing: 11/16/2011
Page 1 of 5
UN -036 —1/4 www- unidocs.org Rev. 01/17 /08
Monitoring System Certification
D. Results of Testing/Servicing
Software Version Installed:
Complete the following checklist:
4 Q:�oi A�
r�
• Yes
❑ No*
Is the audible alarm operational?
• Yes
❑ No*
Is the visual alarm operational?
• 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
19 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) ❑ Sump/Trench Sensors; ❑ 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*
® 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.
® Yes
❑ No*
Was monitoring system set -up reviewed to ensure proper settings? Attach set up reports, if applicable
® Yes
1 ❑ 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: SITE HAS NO POSITIVE SHUTDOWN OR FAIL SAFE. MUST PERFORM ANNUAL LINE TESTING.
Page 2 of 5
UN -036 — 2/4 www.unidocs.org Rev. 01/17108
Morritoring System Certification
F. In -Tank Gauging / SIR Equipment:
Ltq3oz--- P,
® 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?
N Yes
❑ No*
Were all probes reinstalled properly?
P CYes
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):
Cmmnlete the fnllnwinv 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.; ❑ 0.1 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?
N 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
LE Yes
❑ No*
Were all items on the equipment manufacturer's maintenance checklist completed?
In Nection H, below, describe how and when these deficiencies were or will be corrected.
H. Comments:
UN -036 - 3/4
Page 3 of S
www.unidoes.org
Rev. 01/17/08
Monitoring System Certification
I UST Monitoring Site
SiW Addr*s: 232Q j!Ar1 k m -A I
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- ----
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Date map was drawn: -
Ins'- nedons
If you alre have a diagram that shows all required information, you may include it, rather than this page, with your
Monitoring System Certification. On your site plan, show the -general layout of tanks and piping. Clearly identify
locations o ,the following equipment, if installed: monitoring system control panels; sensors monitoring tank annular
spaces, sumps, dispenser pans, spill containers, or other secondary containment areas; mechanical or electronic line leak
detectors; and in -tank liquid levcl probes (if used for leak detection). In the space provided, note the date this Site Plan
was prepared.
Page of 05100
g43c) v
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 (if applicable), should be provided to the facility owner /operator for submittal to the local regulatory agency.
1. FACILITY INFORMATION
Facility Name: MIKES FOOD & LIQUOR
Date of Testing: 11/16/11
Facility Address: 2300 PANAMA LANE
Facility Contact: MIKE
Phone:
Date Local Agency Was Notified of Testing:
Name of Local Agency Inspector (f present during testing): ERNIE MEDMA
2. TESTING CONTRACTOR INFORMATION
Company Name: RICH ENVIRONMENTAL
Technician Conducting Test: RICH PHILLIPS
Credentials: ❑ CSLB Contractor X 1CC Service Tech. ❑ SWRCB Tank Tester ❑ Other (Spec)
License Number(s): 1035169 -UT
3. SPILL BUCKET TESTING INFORMATION
Test Method Used: X Hydrostatic ❑ Vacuum ❑ Other
Test Equipment Used: VISUAL
Equipment Resolution: 0
.3..a
Identify Spill Bucket (By Tank
Number, Stored Product, etc.)
t
87 FILL
2
91 FILL
DIESEL
4
Bucket Installation Type:
X Direct Bury
❑ Contained in Sump
X Direct Bury
❑ Contained in Sump
X Direct Bury
❑ Contained in Sump
❑ Direct Bury
❑ Contained in Sum
Bucket Diameter.
12"
12"
12"
Bucket Depth:
14"
14"
10"
Wait time between applying
vacuum/water and start of test:
30 MIN
30 MIN
30 MIN
Test Start Time (Ti):
9:00
9:00
9:00
Initial Reading (Rt):
14"
14"
10"
Test End Time (TF):
10:00
10:00
10:00
Final Reading (RF):
14"
14"
10"
Test Duration (TF —Ti):
1 -HOUR
1 -HOUR
1 -HOUR
Change in Reading (RF - R,):
0
0
0
Pass/Fail Threshold or
Criteria:
+/-0.00
+/-0.00
+/-0.00
Test Result'.
X Pass ❑ Fail
X Pass ❑ Fail
❑ Pass X Fail
❑ Pass ❑ Fail
COMMentS — (include information on repairs made prior to testing, and recommended follow -up for failed tests)
CERTIFICATION OF CHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING
I hereby certify that all the i rmation contained in this report is true, accurate, and in full compliance with
legal requirements.
Technician's Signature: Date: 11/16/11
OV
1 State laws and regulations do not currently require testing to be performed by a qualified contractor. However, local requirements
may be more stringent.
Lt � -�02-- 1:
RICH ENVIRONMENTAL
5643 BROOKS CT. BAKERSFIELD, CA. 93308
OFFICE (661)392 -8687 FAX (661)392 -0621
PRODUCT LINE LEAK DETECTOR TEST
WORK SHEET
FACILITY NAME: MIKE'S FOOD & LIQUOR
FACILITY ADDRESS: 2300 PANAMA LANE, BAKERSFIELD
PRODUCT LINE TYPE: PRESSURE
PRODUCT
LEAK DETECTOR TYPE
TEST
TRIP
PASS
BELOW
P.S.I.
OR
SERIAL NUMBER
3 G.P.H.
FAIL
87
L/D TYPE: RJ DIAPHRAM
YES
10
PASS
SERIAL #_
91
LID TYPE: RJ FX1V
YES
11
PASS
SERIAL # _
DIESEL
L/D TYPE: RJ FXIDV
YES
10
PASS
SERIAL # _
L/D TYPE:_
YES
PASS
SERIAL # _
NO
FAIL
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 PH IPS
SIGNATURE: DATE: 11/16/11
(9IKES UNOGHL
4aa PANAMA LANt
60KtRSFIELD, CA yJJa(
SITE w 06061
11 /116 /20ii
atf ;l>s Am
TANK SETUP
RtPOKI
LANK NO. 1
i0000 bHL
UNLEADED
Ktu
( ANK i YPE,.
SYSTEM PHIL
-TANK OiMs
tsnYr
TANK SIZE
1016010
1HNK SHAPE
LYLLNUtK
DIAMETER
7b.aa
LENGTH
JL4.aa
PRODUCT UNLEAOtu Ktb
OFFSET P
1.Lz)
OFFSET W
0.00
MANIFOLD
NUNt
PROBE
�lU 1101
FLOATS
1
FLOAT TYPE
6AbuLlNt
GRADIENT
b.yaas
SENSOR LENGTH
101
HI6H LIMIT
6z). 010
LOw LIMIT
10SL.00
H16H HIGH
ya.aa
LOW LOW
r.a16
WATER LIMIT
J.qa
!EMP COMP
API btr/D4rs
API GRAVITY
ALPHA
SLa.ba
Nu. RTUS
RTD LOC 1
11.47
KTU LOC L
S16.yS
KTU LOC 3
4a.tsi
RTO LOC 4
ba :4r
k7U LOC 5
rr.ly
STRAPPING
DRik
INCHES
tHLLUNS
0.1600
a.q
10.000
Jbl.l
20.000
13SL.b
S0.00e
v ll.a
40.000
4ga4.r
5a.ea6
33416.3
h0.006
bbrb.l
70.006
rySZ.a
8x.060
m 41.r
ya. 000
yt$ds p. is
MIKES
UNULHL
1Jai� PANHI'IH LHNt
EAKERSrIELD, LH ySS16/
SITE bbgal
it /16 /201i
10:03 HII
ALARM HISTORY KtrUKI
y /19 /20ii
IY:Jy rw
SYSTEM PHIL
T EftPERA I UKE
ERROk
HNYti NO. 3
`/',6 /20ii
i1:,+1 r1'I
SYSTEM FAIL
(EI`IPERr',TUKE
tKKUK
TANK NO. 3
5 /18/2ail
04c016 H1'I
POWER DOWN
y�O /261i
164:1616 H(ti
POWER UN
!1/16/2011
gtf:Ja Hl'I
UNL SUAP
11 /i6/20il
U6:30 HI`I
UNL SUMP
li /lb /2011
U6"Z)l HI'I
SUPER SoNp
11/16 /2ail
ati:Jb Hi4
SPLIT ANULuS
ii /i6 /20ii
ub:Dr HN
UNL ANULAR
12 / 16/ 23111
0t$; od Hrl
ultSEL SUMP
Mlr%tb VNULHL MIKES UNOIRL
2. fgO t ANAMH LkNt 2300 PANAMA LRNt
6AKERSFiEL(Ji GH 'JJ,Wf UNOt kL
biTE ff SITE 4 o0vol 3@0 PANAMA LANE
6AKERSFiELD, CA
1/46/2011 Hm ii/a6/20i! ob;z( H19 SITE 0
TANK 5E1UP Ktf'uxj TANK SETUP kEPOKi 11/16/2)311
ACTIVE ALARM
ANK No. D0510 UHL TANK NO. 2 OWO UHL
UNLEAOEv bur DLESEL LOW LINIT
ANK TYPI- - TANK TYPE TANK NO.
CLEARED
HNK DIMS uAlb THNK DIMS
RNK Silt Wou TANK SIZE Jaaa
ANK SmApt UYLINVtX Ti4NK SHAPE GYLINVtX
)IAMETER 'Jb.UU DIAMETER 'jb. Vo
.ENGTH Lbl.aa LENGTH IbZ.0U
'RODUCT UNLtAVtU bU,- PRODUCT VItt5tL
jFFSET P 2.atl OFFSET P 'I . uli MIKES UNOLkL
jFFSET W a. 1010 OFFSET W a, as 2•00 PANAMN LANt
I ri
ANiFOLD Nut MANIFOLD NUNL EAKERSFiEL�, CA
=ROBE 61v lul PR06E z)jv Vol SITE oo6o,
-LOA*fS z FLOATS le
:LOA'f TYPE ORaULINt FLOAT TYPE UiL 14/16/2011 06;, v
zRADIENT J. lozo ( GRADIENT �p. ko I jo ALARm kteuxl
TENSOR LEN&Tm lul SENSOR LENGTH 1101 7/3/2011
liGH LIMIT u Z) I fafa mIGh LIMIT 00.150
LOW LliliT 141010.100 LOW LIMIT oclou. ou SYSTEM FAIL
mian H16H �lv. uu Hiam HIGH 100.010 TEMPERATORE ERkok
VANK N
LOW LOW t. IOU LOW LOW r. as 6.
WATER LIMIT .3. U0 WATER LIMIT '). ut, 7/15/2ell
fEmP COMP ki bz/346 TEMP comp API bd/340
Arai GRAVITY Z) I. )a API GRAVITY .) Z. Wo
HLPHA JLa.aa ALPHA 43. Ufa TANK NO.
NO. RIGS J nC). RTDS 3 //26/2G11
kYU LOC I RIG �-Oc I 11.410 vo I-pl
kTO LOl. 2 J4. yJ RTO LOG 2 1W. li 3 SYSTEM FAIL
kTD LOC J 40.di R-D LOC 3 143. d I TEilPERATURE Ekk6x
RTD LOG 4 40.14( RT'D LOG 4 blO.'+( TAB` iK No.
kTD LOC 5 ft.l10 RTD LOG 5 el.1i
sykAPPINO OAIH STRkPPIN6 f)H'i'H LOW LIMIT 101:110 rPi
INCHES UHLLUNb 4`60HES UHLLUNti
6.066 10. t) 0.00e a.0
0. oft caa. a 16.066 tDu. z
20.000 rbb..) ebb.,) POWER DOWN
30.000 1 )Z)Z). 3 3b. 0176 !,)D3. Z) 7I1112011
40.000 Laat.J zme.') Hil
50.000 z b I POWER UP
kso6 JJJi5.10 tr0. 06l� 1)"b. u - 'JI !,+/20 1
1►00 J10ba.3 70.000 )to bb. S SYSTEM FAIL
vn,00 14 0;4 0. tS 80.000 40110. ts 'iEMPERATURE ERROk
106.060 4744.7 90.000 41044.7 TANK No, 3
9/16/2611 12;41 rrl
SYSTEM FAIL
TEOPERAl-URE ERRcjk
TANK NO. 5
9/18/2611 44:Vb
POWER DOWN Hri
POWER t)p
g43DZ--
;t
MONITOR CERT. FAILURE REPORT
SITE NAME: /7'I1 K,j- %° °rJ � Z, qv�n- DATE: / /--/ �-1 )
ADDRESS: ti3o- A L)✓ TECHNICIAN: RICHIE PHILLIPS
CITY: 13X Je-kh-J ,�,AE-449 , Zj� SIGNATURE:
REPAIRS: A,-o /� aJ T`1 VE ,i l�- T d o w /✓
PARTS INSTALLED:
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 ENVIRONMANTAL 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.