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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 ----- - - - - -- ------------=- 5-= = - - - -= - -- - - - - -- - - - - -- - - -- ' ------------------- L:_:.r.J---------- - - - - -- ---------------------------------------.---'---------- - - - -�� - -- Ufa - - - - - -- - - - - - - - - - - - - - - - - -�' - - '�- -- -- - = - - -- ------------------------- -- - -- - - - -- -- - ----•----- - - -- ---- - --- - - -� -- - - - - - - -- - - - - -- - - - - - - - - - - - - - - ----- - - - - -- - -? - -- - Q -- -- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -_ -- - -� - " - - - - - - - - - - - - - - - - - - - - - - - - - - - - - ---- --- f�-- - - - - -- - - -- - -- - ----- - - - - -- ---- - - - - - - - - - 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.