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Home My WebLink AboutFMC 5-30-14MONITORING SYSTEM CERTIFICATION For Use By All Jurisdiclions Within the State ofCal!fornia . Awhority Ciied: Chapler 6. 7, Health and Safety Code; Chapter 16, Division 3, Title 23, California Code of Regula/ions 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: USA Liquor Bldg. No.: ___ _ Site Address: 1720 South Union Avenue City: Bakersfield Zip: ..;;.9.:....33:....;0;...;.7 __ _ Facility Contact Person: Ronnie Contact Phone No.: (661) 832-0457 Make/Model of Monitoring System: Veeder-Root TLS-350 Date ofTesting/Servicing: 513012014 B. Inventory of Equipment Tested/Certified -------------~ --. -------·-----------------------~-------------~-----·---. ----- Tank TD: 10000 gal. Regular Tank ID: 10000 gal. Su(!er 1:8J In-Tank Gauging Probe. Model: 847390-107 [8J In-Tank Gauging Probe. Model: 847390-107 [8J Annular Space or Vault Sensor. Model: 94390-420 [8J Annular Space or Vault Sensor. Model: 794390-420 I:8J Piping Sump I Trench Sensor(s). Model: 794380-208 [8J Piping Sump I Trench Sensor(s). Model: 794380-208 0 Fill Sump Sensor(s). Model: 0 Fill Sump Sensor(s). Model: 1:8J Mechanical Line Leak Detector. Model: FX1V ~ Mechanical Line Leak Detector. Model: FX1V 0 Electronic Line Leak Detector. Model: 0 Electronic Line Leak Detector. Model: [8J Tank Overfill/ High-Level Sensor. Model: OPW-61-SO 1:8J Tank Overfill/ High-Level Sensor. Model: OPW-61-SO 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 ID: 10000 gal. Diesel Tank 10: 1:8J In-Tank Gauging Probe. Model: 847390-107 0 In-Tank Gauging Probe. Model: 1:8J Annular Space or Vault Sensor. Model: 794390-420 0 Annular Space or Vault Sensor. Model: ~ Piping Sump I Trench Sensor(s). Model: 794380-208 0 Piping Sump I Trench Sensor(s). Model: 0 Fill Sump Sensor(s). Model: 0 Fill Sump Sensor(s). Model: 1:8J Mechanical Line Leak Detector. Model: FX1 DV 0 Mechanical Line Leak Detector. Model: 0 Electronic Line Leak Detector. Model: 0 Electronic Line Leak Detector. Model: [8J Tank Overfill I High-Level Sensor. Model: OPW 61-50 0 Tank Overfill/ High-Level Sensor. Model: 0 Other (specifY equipment type and model in Section Eon Page 2). 0 Other (specify equipment type and model in Section Eon Page 2). Dispenser JD: 1&2 Dispenser ID: 3&4 0 Dispenser Containment Scnsor(s). Model: 0 Dispenser Containment Sensor(s). Model: [8J Shear Valvc(s). [8J Shear Valve(s). 1:8J Dispenser Containment Float(s) and Chain(s). [8J Dispenser Containment Float(s) and Chain(s). Dispenser ID: Dispenser ID: 0 Dispenser Containment Sensor(s). Model: 0 Dispenser Containment Sensor(s). Model: 0 Shear Valve{s). 0 Shear Valve(s). 0 Dispenser Containment Float(s) and Chain(s). 0 Dispenser Containment Float(s) and Chain(s). Dispenser ID: Dispenser ID: 0 Dispenser Containment Sensor(s). Model: 0 Dispenser Containment Sensor(s). Model: 0 Shear Valve(s). 0 Shear Valve(s). 0 Dispenser Containment Float(s) and Chain(s). 0 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; (clteck all tltat app~y): IZ! System set-up ~IZ! Alarm hi:~ report Technician Name (print): Bradley Seykora Signature:,.._...:::..,. ~~-===~,q.-=-------------- Certification No.: B40738 License. N .. 8049 ~~~..;;._ ____________ ___ Testing Company Name: Confidence UST Services, Inc. Phone No.: (800) 339-9930 Site Address: 1720 South Union Avenue, Bakersfield, CA 93307 Date ofTesting/Servicing: 5/30/2014 Page 1 of 3 I Monitoring System Certification D. Results of Testing/Servicing Software Version Installed: 424.00 ~~~--------------------------- ~ heckr ~ ~ 0 Yes 0 No* Is the audible alarm operational? 0 Yes 0 No* Is the visual alarm operational? 0 Yes 0 No* Were all sensors visually inspected, functionally tested, and confirmed operational? 0 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* If alarms are relayed to a remote monitoring station, is all communications equipment (e.g., modem) 0 N/A operational? 0 Yes 0 No* For pressurized piping systems, docs the turbine automatically shut down if the piping secondary containment 0 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) 0 Sump/Trench Sensors; 0 Dispenser Containment Sensors. Did you confirm positive shut-down due to leaks and sensor failure/disconnection? 0 Yes: 0 No. 0 Yes 0 No* For tank systems that utilize the monitoring system as the primary tank overfill warning device (i.e., no I 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 oftank capacity does the alarm trigger? -61% 0 Yes* 0 No Was any monitoring equipment replaced? If yes, identity specific sensors. probes, or other equipment replaced and list the manufacturer name and model for all replacement parts in Section E, below. 0 Yes* 0 No Was liquid found inside any secondary containment systems designed as dry systems? (Check all that apply) 0 Product; 0 Water. If yes, describe causes in Section E, below. 0 Yes 0 No* Was monitoring system set-up reviewed to ensure proper settings? Attach set up reports, if applicable 0 Yes 0 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: Page 2 of 3 Monitoring System Certification F. In-Tank Gauging I SIR Equipment: 0 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 equipment is used to perform leak detection monitoring. Complete the following checklist: 0 Yes 0 No* Has all input wiring been inspected for proper entry and termination, including testing for ground faults? 0 Yes 0 No* Were all tank gauging probes visually inspected for damage and residue buildup? 0 Yes 0 No* Was accuracy of system product level readings tested? 0 Yes 0 No* Was accuracy of system water level readings tested? 0 Yes 0 No* Were all probes reinstalled properly? 0 Yes 0 No* Were all items on the equipment manufacturer's maintenance checklist completed? * In the Section H, below, describe how and when these deficiencies were or will be corrected. G. Line Leak Detectors (LLD): 0 Check this box ifLLDs are not installed. c -------------- 181 Yes 0 No* For equipment start-up or annual equipment certification, was a leak simulated to verify LLD performance? 0 N/A (Check all that apply) Simulated leak rate: 181 3 g.p.h.; 0 0.1 g.p.h ; 0 0.2 g.p.h. 18] Yes 0 No* Were all LLDs confirmed operational and accurate within regulatOiy requirements? 18] Yes 0 No* Was the testing apparatus properly calibrated? 181 Yes 0 No* For mechanical LLDs, does the LLD restrict product tlow 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? 18] N/A 0 Yes 0 No* For electronic LLDs, does the turbine automatically shut off if any portion of the monitoring system is disabled 18] N/A or disconnected? 0 Yes 0 No* For electronic LLDs, does the turbine automatically shut off if any p01tion of the monitoring system malfunctions 18] N/A or fails a test? 0 Yes 0 No* For electronic LLDs, have all accessible wiring connections been visually inspected? 181 N/A 18] Yes 0 No* Were all items on the equipment manufacturer's maintenance checklist completed? * In the Section H, below, describe how and when these deficiencies were or will be corrected. ~. Commenh: Re~~of~eDi~~e~I~LuLD~. ~~~~~~~~~~~~~~~~~~~~~~~~~~ Page 3 of 3 Name: Street: ~flDf"+. CJO (\~ \UST; .,. ~· ,.liuc"f\0 1lULO wmi COHFID£NC>'' Lic.970703 ~flO~+. CJO ~ ~UST(j -,,CES•~ ~WITH CONFIOtNCC' Lie. 804904 Toll Free #: 1-800-339-9930 Confidence UST 16250 Meacham Road Job Order /Invoice #: 32<-/lsA- Date catted llme I ToWhom Site Name: U5A" ~~llnr.\' Street: T City: Bakersfield. CA 93314 City: -~t.(S"J;P,LA State: C. >4--__ Zip: Terms: Store No: Descrip_tion of work oerformed: L.. :6 r~l Abrf-A CbS'L ~~k:r \ • ~~~ ... J' ucfer ,'.u L }v'e.SPJ, 14w.hlhr ~~e . A-J..!J.P r fp~o\h:VL.. ~ v~r-~-~ 'vk;'i______&1.cJ 2~&k /jtJ;;t ~~ ~Jun.,,.,~ ~-~-All FuNdic.J...J~ ) . .Jan.A.c..1 ~ f? ~{;.<;J1,.LJ bJ~SP I LLL \.J -,ge,_ (> p ;._~ ·t; c.:; I, eN. ,~SPuJUr-OS £ ,:J-ve~S ~-~.4 ~ g, ~s..ft.Jl' ~r/oJ-r~ Vl;_ Uow1~~..L r v TRAVEL and LABOR (0.5 Hour Minimum Labor Charge) OVERTIME (5:00 PM -7:00AM) Date I Te;:~niclan(s) Name Start End Total OT Start OTEnd OTTotal 1,-A,~lll gr...::> ... ~v' ~ykG,~ Travel I: I~ J: '{S" .$" 1->r / -/ Labor I: 'IS-z_:'{s-1-r Travel 2:4~ ~: f'S .5r.-t- Date Technocian(s) Name Start End Total OT Start OTEnd OTTotal Travel Labor Travel Dato Techniclan(s) Name Start End Total OTStart OTEnd OTTotal Travel Labor Travel SUPPLIES-MATERIALS-RENTALS Check One Qty. UST Parts I Site Parts I .11. ,.-_., ~ J-:--1 drGf? ~ \(..?~( ,__rr /~ . ,.--..... ~ 'illJl \ "\ \'(#" \../ _ll ~ COMMENTS Store Employee Print Name: IN VOl