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MONITORING SYSTEM CERTIFICA'T'ION
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 Asogarate certification or report must be prcparcd for each
monitoring wstem 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
ORANGE BELT STAGES
Site Address: 3640 SILLECT AVE City: BAKERSFIELD
Facility Contact Person: MATT Contact Phone No.:
Make/Model of Monitoring System: TLS -350 INSP. ERNIE MEDINA
B. ]Inventory of Equipment 'Tested/Certified
Check the appropriate boxes to indicate specific equipment inspected/serviced-
Z
Bldg. No.:
ip: 93308
Date of Testing/Servicing: 6/27/2011
Tank ID: DIESEL
Tank ID:
❑ In -Tank Gauging Probe.
Model:
® In -Tank Gauging Probe. Model: MAGI
® Annular Space or Vault Sensor.
Model: TRANSDUCER
❑ Annular Space or Vault Sensor.
Model:
® Piping Sump / Trench Sensor(s).
Model: 208
❑ Piping Sump / Trench Sensor(s).
Model:
❑ Fill Sump Sensor(s).
Model:
❑ Fill Sump Sensor(s).
Model:
® Mechanical Line Leak Detector.
Model: FX1DV
❑ 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).
Tank ]D:
Tank II?:
❑ 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 Sensor(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: 1
Dispenser ID:
® Dispenser Containment Sensor(s),
Model: 001
❑ 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).
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).
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 generating such reports, I have also
attached a copy of the report; (check all that apply): ® System set -up ® Alarm history report
Technician Name (print): RICHARD MASON Signature:
--o
Certification No.: B36880 / 5297857 -UT License. No.: C611 D40 809850
Testing Company Name: Rich Environmental Phone No.: 661)_ 392 -8687
Testing Company Address: 5643 BROOKS CT. BAKERSFIELD, CA 93308
Page 1 of 5
Date of Testing/Servicing: 6/27/2011
UN-036-1/4 www.unidomorg Rev. 01117/08
Monitoring System Certification
D. Results of 'Testing/Servicing
Software Version Installed:
Complete the following checklist:
qib-ta I` �i
® 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)
E N/A
operational?
E 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? E Yes; ❑ No.
❑ Yes
❑ No*
For tank systems that utilize the monitoring system as the primary tank overfill warning device (i.e., no
E 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*
E 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.
E Yes
❑ No*
Was monitoring system set -up reviewed to ensure proper settings? Attach set up reports, if applicable
E Yes
❑ No*
I 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:
Page 2 of 5
LTI -036 — 214 www.unidomorg Rev. 01 /17/08
Monitoring System Certification
F. In -Tank Gauging / SIR Equipment:
L"10 /
® 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):
f mmnloto the fnllnwina rhprklict-
❑ 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 ; [10.2 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.
H. Comments:
UN-036-3/4
Page 3 of 5
www.unidomorg
Rev. 01/)7/08
Monitoring System Certification Form: Addendum for Vacuum/Pressure Interstitial Sensors
1. Results of Vacuum/Pressure Monitoring Equipment Testing
This page should be used to document testing and servicing of vacuum and pressure interstitial sensors. A copy of
this form must be included with the Monitoring System Certification Form, which must be provided to the tank
system owner /operator. The owner /operator must submit a copy of the Monitoring System Certification Form to the
local agency regulating UST systems within 30 days of test date.
Manufacturer: MORRISON EROS
Model: TRANSDUCER System Type: ❑ Pressure; ® Vacuum
Sensor ID
Component(s) Monitored by this Sensor: DIESEL ANNULAR
L:2
Sensor Functionality Test Result: ® Pass; ❑ Fail Interstitial Communication Test Result: ® Pass; ❑ Fail
Component(s) Monitored by this Sensor:
Sensor Functionality Test Result: ❑ Pass; ❑ Fail Interstitial Communication Test Result: ❑ Pass; ❑ Fail
Component(s) Monitored by this Sensor:
Sensor Functionality Test Result: ❑ Pass; ❑ Fail Interstitial Communication Test Result: ❑ Pass; ❑ Fail
Component(s) Monitored by this Sensor.
Sensor Functionality Test Result: ❑ Pass; ❑ Fail Interstitial Communication Test Result: ❑ Pass; ❑ Fail
Component(s) Monitored by this Sensor:
Sensor Functionality Test Result: ❑ Pass; ❑ Fail Interstitial Communication Test Result: ❑ Pass; ❑ Fail
Component(s) Monitored by this Sensor:
Sensor Functionality Test Result: ❑ Pass; ❑ Fail Interstitial Communication Test Result: ❑ Pass; ❑ Fail
Component(s) Monitored by this Sensor:
Sensor Functionality Test Result: ❑ Pass; ❑ Fail Interstitial Communication Test Result: ❑ Pass; ❑ Fail
Component(s) Monitored by this Sensor:
Sensor Functionality Test Result: ❑ Pass; ❑ Fail Interstitial Communication Test Result: ❑ Pass; ❑ Fail
Component(s) Monitored by this Sensor:
Sensor Functionality Test Result: ❑ Pass; ❑ Fail Interstitial Communication Test Result: ❑ Pass; ❑ Fail
Component(s) Monitored by this Sensor:
Sensor Functionality Test Result: ❑ Pass; ❑ Fail Interstitial Communication Test Result: ❑ Pass; ❑ Fail
How was` interstitial communication verified?
❑ Leak Introduced at Far End of Interstitial Space;` ❑ Gauge; ® Visual Inspection; ❑ Other (Describe in Sec..J, below)
Was vacuum /pressure restored to operating levels in all interstitial spaces? ® Yes ❑ No (If no, describe in Sec. J, below)
J. Comments:.
Page 4 of 5
' If the sensor successfully detects a simulated vacuum/pressure leak introduced in the interstitial space at the furthest point from the
sensor, vacuum/pressure has been demonstrated to be communicating throughout the interstice.
L'N -036A - 1/1 www.unidocs.org Rev. 01/26/06
ring System Certificati6n �
UST Monitoring Site Plan
SiIc Ad;iress: 3640 SILLECT AVE BAKERSFIELD, CA 93308 -
Date map was drawn: 6/28.12010.
Instructions
li VOLI alrcadN havc a diagram that shows all required information, you may include it. rather than this pauc. ��411 volli Nd(1nit;),;
5 stem (_'crtification, Un vour site plan. show the general layout of tanks and piping. Clearly identif; location's of the tolls
c;iuipncnt. ii' installed: monitoring, system control panels, sensors monitoring tank annular spaces, sumps. dispenser pions. s,
(:ontairncrs. or other secondan containment areas, mechanical or electronic line leak detectors; and in -tank liquid Icvcl probes
lur =cak detection). In the space provided, note the date this Site Plan was prepared.
Page 5 of 5
[IN - 03(, —.t:a w1iW.1111iducs.ur" k0:01 444'
lAulc) /
RICH ENVIRONMENTAL
3305 BRITTAN ST. BAKERSFIELD, CA. 93308
OFFICE (661)326 -8402 FAX (661)326 -8934
PRODUCT LINE LEAK DETECTOR TEST
WORK SHEET
W /0#:
FACILITY NAME: ORANGE BELT STAGES
FACILITY ADDRESS: 3640 SILLECT AVENUE, BAKERSFIELD, CA
PRODUCT LINE TYPE: PRESSURE
PRODUCT
LEAK DETECTOR TYPE
TEST
TRIP
PASS
BELOW
P.S.I.
OR
SERIAL NUMBER
3 G.P.H.
FAIL
DIESEL
L/D TYPE: RED JACKET
YES
10 P.S.I.
PASS
SERIAL # 6857
L/D TYPE: _
PASS
YES
SERIAL #
FAIL
L/D TYPE: _
PASS
YES
SERIAL #
FAIL
L/D TYPE:
PASS
YES
SERIAL #
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: RICHARD MASON
SIGNATURE: �^ DATE: /27/11
4Zb- lD
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: ORANGE BELT STAGES
Date of Testing: 6/27/11
Facility Address: 3640 SILLECT AVE, BAKERSFIELD, CA
Facility Contact: MATT
Phone:
Date Local Agency Was Notified of Testing: 6 11 /11
Name of Local Agency Inspector (f present during testing): ERNIE MEDINA
2. TESTING CONTRACTOR INFORMATION
Company Name: RICH ENVIRONMENTAL
Technician Conducting Test: RICHARD MASON
Credentials': ❑ CSLB Contractor X ICC Service Tech. ❑ S WRCB Tank Tester ❑ Other (Specify)
License Number(s): 5297857 -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.
1
DIESEL
2
3
4
Bucket Installation Type:
X Direct Bury
❑ Contained in Sump
D. Direct Bury
C Contained in Sump
❑ Direct Bury
❑ Contained in Sump
❑ Direct Bury
❑ Contained in Sum
Bucket Diameter.
12"
Bucket Depth:
14"
Wait time between applying
vacuum /water and start of test:
30 MIN
Test Start Time (Ti):
9:00
Initial Reading (Rj):
10"
Test End Time (TF):
10:00
Final Reading (RF):
10"
Test Duration (TF - T,):
1 -HOUR
Change in Reading (RF -
0
Pass/Fail Threshold or
Criteria:
+/-0.00
Tit I�aIE
t I' 1Iq, _ S-1� .
p
h ,
Comments - (include information on repairs made prior to testing, and recommended follow -up for failed tests)
CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THLS TESTING
I hereby certify that all the information contained in this report is true, accurate, and in full compliance with legal requirements.
`T'echnician's Signature: � �- Date: 6/27/11
' State laws and regulations do not currently require testing to be performed by a qualified contractor. However, local requirements
may be more stringent.
ALARM HISTORY REPORT
- - - -- SENSOR ALARM - - - --
L i:DIESEL STP SUMP
STP SUMP
SENSOR OUT ALARM
.JUN 27. 2011 9:15 AM
FUEL ALARM
JUN 27, 2011 9:05 AM
FUEL ALARM
JUN 28, 2010 8:51 AM
ALARM HISTORY REPORT
SENSOR ALARM
L 1:DIESEL STP SUMP
STP SUMP
SENSOR OUT ALARM
JUN 27, 2011 9:15 AM
FUEL ALARM
JUN 27, 2011 9:05 AM
FUEL ALARM
JUN 28, 2010 8:51 AM
ALAR1,1 HISTORY REPORT
SENSOR ALARM
L 21-DIESEL ANNULAR
ANNULAR SPACE
FUEL ALARM
JUN 27, 2011 9:15 AM
FUEL ALARM
JUN 27, 2011 9:08 AM
START TIME : DISABLED
TEST RATE :0.20 GAL /HR
DURATION : 2 HOURS
LIQUID SENSOR SETUP
L 1:DIESEL STP SUMP
TRI -STATE
CATEGORY : STP SUMP
L 2:DIESEL ANNULAR
NORMALLY CLOSED
CATEGORY : ANNULAR SPACE
COMMUNICATIONS SETUP
PORT SETTINGS:
NONE FOUND
RS -232 SECURITY
CODE : 000000
RS -232 END OF MESSAGE
DISABLED
OUTPUT RELAY SETUP
F. 1:POSITIVE SHUTDOWN
TYPE:
STANDARD
NORMALLY CLOSED
LIQUID SENSOR ALMS
L 1 :FUEL ALARM
L 2:FUEL ALARM
ALL:SENSOR OUT ALARM
SYSTEM SETUP M uo N
JUN 27, 2011, 8:32 AM
SYSTEM U14I TS
U.S.
SYSTEM LANGUAGE -
ENGLISH
ORANGE BELT STAGES
3640 SILLECT AVE
BAKERSFIELD, CA
SHIFT TIME 1 DISABLED
SHIFT TIME 2 DISABLED
SHIFT TIME 3 DISABLED
PERIODIC TEST WARNINGS
DISABLED
ANNUAL TEST WARNINGS
DISABLED
SYSTEM SECURITY
CODE : 000000
IN -TANK SETUP
T I:DIESEL
PRODUCT CODE 1
THERMAL COEFF• :.000450
TANK. DIAMETER 95.00
TANK PROFILE 1 PT
FULL VOL 11783
FLOAT SIZE: 4.0 INCHES
WATER WARNING
2.0
HIGH WATER LIMIT:
3.0
MAX OR LABEL VOL:
11783
OVERFILL LIMIT
90%
10604
HIGH PRODUCT
95%
11193
DELIVERY LIMIT
5%
589
LOW PRODUCT 1000
LEAK ALARM LIMIT: 99
SUDDEN LOSS LIMIT: 99
TANK TILT 0.00
MANIFOLDED TANKS
T#: NONE
PERIODIC TEST TYPE
STANDARD
PERIODIC TEST FAIL
ALARM DISABLED
GROSS TEST FAIL
ALARM DISABLED
FUEL ALARM
JUN 26, 2010 8 :52 AM SOFTWARE REVISION, LEVEL PER TEST AVERAGING; OFF
VERSION 6.01 TANK TEST NOTIFY: OFF
SOFTWARE# 612760- 006 -B
CREATED - 94.02.20.15.19 TNK TST SIPHON BPEAK:OFF
NO �qnFTLIDAW M7•Nlt IT F
qVial 0 /
MONITOR CERT. FAILURE REPORT
SITE NAME : ORANGE BELT STAGES DATE : 6/27/11
ADDRESS: 3640 SILLECT AVE TECHNICIAN: RICHARD MASON
CITY : BAKERSFIELD SIGNATURE: ��--
THE FOLLOWING COMPONENTS WERE REPLACED/REPAIRED TO COMPLETE
TESTING.
REPAIRS: NONE
LABOR: NONE
PARTS INSTALLED: NONE
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.