HomeMy WebLinkAboutFMC 2011r2-,.
MONITORING SYSTEM CERTIFICATION
For Use By All Jurisdictions Within the State ofCalifornia
Authority Cited: Chapter 6 7, Health and Safety Code; Chapter 16, Division 3, Title 23, California Code ofRegulations
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 this date.
A. General Information
Facility Name: SamCo Food Store # 2
Site Address: 3300 White Lane
Facility Contact Person: Sam Jouda /Sam Jr.
Make /Model of Monitoring System: Veeder Root TLS -350
B. Inventory of Equipment Tested /Certified
Checkthe appropriate box" to indicate specific equipment inspected /serviced:
City: Bakersfield
Bldg. No.:
Zip: 93309
Contact Phone No.: (661)333- 0000/472 -9090
Date of Testing/Servicing: 12/22/2011
Tank ID: 12000 gal. Regular Tank ID: 12000 gal. Super
x] In -Tank Gauging Probe. Model: 847390 -107X] In -Tank Gauging Probe. Model: 847390-107
x] Annular Space or Vault Probe. Model: 794390-420 U Annular Space or Vault Sensor. Model: 794390 -420
x] Piping Sump / Trench Sensor(s). Model: 794380 -208 Lx] Piping Sump / Trench Sensor(s). Model: 794380 -208
X] Fill Sump Sensor(s) Model: 794380 -208 Fill Sump Sensor(s). Model: 794380 -208
Lx I Mechanical Line Leak Detector. Model:FX1V x] Mechanical Line Leak Detector. Model: FX1V
Electronic Line Leak Detector. Model: Electronic Line Leak Detector. Model:
x] Tank Overfill / High Level Sensor. Model: 847390 -107 U Tank Overfill / High Leval Sensor. Model: 847390 -107
Other (specify equip. type and model in Sec. E on Pg. 2) Other (specify equip. type and model in Sec. E on Pg. 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 Sensors(s). Model: Fill Sump Sensor(s). Model:
Mechanical Line Leak Decector. 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 equip. type and model in Sec. E on Pg. 2) Other (specify equip. typs and model in Sec. E on Pg. 2)
Dispenser ID: 1 & 2 Dispenser ID: 3&4
n Dispenser Containment Sensor(s). Model: 794380 - 208 X] Dispenser Containment Sensor(s). Model: 794380 -208
X] Shear Valve(s). x] Shear Valve(s).
Dispenser Containment Float(s) and Chain(s). Dispenser Containment Float(s) and Chain(s)
Dispenser ID: 5 & 6 Dispenser ID: 7 & 8
Lx] Dispenser Containment Sensor(s). Model: 794380 -208 x] Dispenser Containment Sensor(s). Model: 794380 -208
Lx] Shear Valve(s). X] Shear Valve(s).
Dispenser Containment Float(s) and Chains(s). Dispenser Containment Float(s) and Chain(s).
Dispenser ID: 9 -10 Dispenser ID: 11 -12
L] Dispenser Containment Sensor(s). Model: 794380 - 208 x] Dispenser Containment Sensor(s). Model: 794 - 380 -208
x] Shear Valve(s). x] 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 -1 certify that the equipment identified in this document was inspected /services in accordance with the
manufacturers' guidlines. Attached to this Certification is information (e.g. manufacturers' checklist) necessary to varify that
this information is correct and a plot plan showing the layout of monitoring equipment. For equipment capable of generating
such reports, I have attached a copy ofthe report; (check all that apply) EX] S m Set -up x] Al his ry report
Technician Name (print): Bryan A Self Signature:
Certification No: 837501 License No: 804904
Testing Company Name: Confidence UST Services, Inc. Phone No: 800- 339 -9930
Site Address: 3300 White Lane, Bakersfield, CA 93309 Date of Testing/Servicing: 12/2212011
D. Results of Testing /Seryicing
Software Version Installed: 329.00
Complete the following checklist:
Lx] Yes No* Is the audible alarm operational?
x Yes No* Is the Visual a arm operational?
x Yes ENO* Were all sensors visually inspected, functionally tested, and confirmed operational?
x I Yes No* Were all sensors installed at the lowest point of secondary containment and positioned so that other
equipment will not interfere with their proper operation?
El Yes No* If alarms are relayed to a remote monitoring station, is all communications equipment (e.g. modem) Hx N/A operational?
x Yes No* For pressurized piping systems, does the turbine automatically shut down if the piping secondary
N/A containment monitoring system detects a leak, fails to operate, or is electrically disconnected? If yes:
which sensors initate positive shut -down? E Sump /Trench Sensors [x] Dispenser Containment Sensors
Did you confirm positive shut -down due to leaks and sensor failure /disconnected? [x] Yes; No;
U 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 visual and audible at
the tank fill point(s) and operating properly? If so, at what percent of tank capasity does the alarm
trigger? L90 %
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* U No Was liquid found inside any secondary containment systems designed as dry systems?
Product; Water. If yes, describe causes in Section E, below.
Was monitoring system set -up reviewed to ensure proper settings? Attach set -up reports, if applicable. MesNo*
No* I Is all monitoring equipment operational per manufacturer's specifications?
In Section E below, discribe how and when these deficiencies were or will be corrected.
E. Comments' During the Monitoring Certification the Regular STP Sump 208 Sensor, Regular 420 Annular Sensor, and
the Regular FX I V Line Leak Detector Failed. After both Sensors and the new FX 1 V Leak Detector were installed on the
Regular Tank, these itemes were re- tested and confirmed operational.
Also when we were running the initial Spill Bucket Testing the Regular Phil Tite Spill Bucket was failing, due to a leaking
drain Valve. We installed a new Phil Tite Spill Bucket and ran another test, and it was also confirmed operational.
F. In -Tank Guaging / SIR Equipment: [X] Check this box if tank guaging is used only for inventory control.
Check this box if tank guaging or SIR equipment is installed.
This section must be completed if in -tank guaging equipment is used to perform leak detection monitoring.
Complete the following checklist:
X] Yes No* Has all input wiring been inspected for proper enter and term ination,including testing for ground faults?
x Yes No* Were all tank guaging probes visually inspected for damage and residue buildup?
x Yes No* Was accuracy of system product level readings tested?
x Yes No* Was accuracy of system water level readings tested?
x Yes No* Were all probes reinstalled properly?
Lx] Yes 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): Check this box if LLD's are not installed.
Complete the following checklist:
Cx] Yes No* For equip. start-up or annual equipment certification, was a leak simulated to varify LLD performance?
Check all that apply) Simulated leak rate: E3 g.p.h.: 0.1 g.p.h.; 00.2 g.p.h.;
x Yes No* Were all LLD's confirmed operational and accurate within regulatory requirments?
x Yes No Was the testing apparatus properly ca i rate ?
L] Yes No For mac amca LLD's, does the LLD restrict product flow if it detects a leak?
N/A
Yes No* For electronic LLD's, does the turbine automatically shut off if the LLD detects a leak?
x] N/A
Yes No* For electronic LLD's, does the turbine automatically shut off ifany portion of the monitoring system is
x] N/A disabled or disconnected?
Yes No* For electronic LLD's, does the turbine automatically shut off ifany portion of the monitoring system
U N/A malfunction or fails a test?
Yes No* For electronic LLD's, have all accessible wiring connections been visually inspected?
U N/A
x Yes Lj 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.
H. Comments: The original FX 1 V Leak Detector on the Regular Failed to catch a leak. It was replaced with a new
FX 1 V Line Leak Detector. Once it was replaced the new FX 1 V Leak Detector was re- tested and confirmed operational.
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SWRCB, January 2006
Spill Bucket Testing Report Form
This.form is intendedfor• use by contractors perfornring annual testing of UST spill containment structures. The completedform and
printoutsfrom tests (if applicable), should be provided to thefacility owner /operator, for submittal to the local regulatory agency.
1. FACILITY INFORMATION
Facility Name: SamCo Food Store #2 Date of Testing: 12/22/2011
Facility Address: 3300 White Lane, Bakersfield, CA 93309
Facility Contact: Sam Jouda /Sam Jr. Phone: 661- 333 - 0000/661- 472 -9090
Date Local Agency Was Notified of Testing : 11/15/2011
Name of Local Agency Inspector (ifpresent during testing): Ernie Medina
2. TESTING CONTRACTOR INFORMATION
Company Name: Confidence UST Services, Inc.
Technician Conducting Test: Bryan A Self
Credentials: X CSLB Contractor X ICC Service Tech. X SWRCB Tank Tester Other (Specify)
License Number(s): CSLB 4804904 ICC #8022804 -UT SWRCB #1 1 -1756
3. SPILL BUCKET TESTING INFORMATION
Test Method Used: X Hydrostatic Vacuum Other
Test Equipment Used: Lake Test Equipment Resolution: 0.0625"
Identify Spill Bucket (By Tank
Number, Stored Product, etc.)
1 Regular (Fill) 2 Super (Fill) 4
Bucket Installation Type: Direct Bury
x Contained in Sump
Direct Bury
x Contained in Sump
Direct Bury
Contained in Sum
Direct Bury
Contained in Sum
Bucket Diameter: 12.00" 12.00"
Bucket Depth: 14.00" 14.00"
Wait time between applying
vacuum /water and start of test: 5 min. 5 min.
Test Start Time (T,): 10:00 AM 9:00 AM
Initial Reading (R,): 11.75" 1 1.25"
Test End Time (Tr): 11:00 AM 10:00 AM
Final Reading (R,:): 11.75" 11.25"
Test Duration (T,: — Ti): 1 hour 1 hour
Change in Reading (R, - R,): 0.00" 0.00"
Pass /Fail Threshold or
Criteria: 0.0625" 0.0625"
Test Result: X Pass Fail X Pass Fall X Pass Fail Pass Fail
Comments — (include information on repairs made prior to testing, and recommended follow -up forfailed tests)
The original Phil Tite Spill Bucket Test on the Regular Failed, due to a leaking
Drain Valve. We replaced the old Bucket with a new Phil Tite Spill Bucket.
Once the new Bucket was installed, it was re- tested and confirmed operational.
CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING
I hereby certify that all the information contained in this report is true, accurate, and in full compliance with legal reyuiremenM
Technician's Signature: 41' ^ A, G / Date: 12/22/2011
State laws and regulations do not curr, fitly require testing t performed by a qualified contractor. However, local requirements
may be more stringent.
of WRA,
UstTxl
I
CokpuAwuW„"co«,100XV Invoice No.. 28142
Site: SamCo Food Store #2
3300 White Lane
Bakersfield, CA 93309
Repairs Requested: Monitoring System Certification, Spill Bucket
Testing, and Leak Detector Testing.
Repairs completed: Monitoring System Certification, Spill Bucket
Testing, and Leak Detector Testing. During the Monitoring
Certification the Regular 208 Sump Sensor, Regular 420 Annular
Sensor, Regular FX1 V Line Leak Detector, and the Regular Phil Tite
Spill Bucket Failed. All of these items were replaced. Once all of
these items were replaced they were all re- tested and confirmed
operational.
Required Repairs, Still Pending: No further repairs are required.
Technician Name: Bryan Self
Signature:
Date: 12/22/2011
1. TLS 350
2.Clean Air Seperator
3.Extier Over Fill Alarm
4.208 Sump Sensor
5.FX1V LLD
6.420 Tank Annular Sensor
7.Tank A.T.G.
F= Fill Spill Bucket
V =Vapor Spill Bucket
SamCO Food Store #2
3300 White Lane
Bakersfield, CA 93309
12/22/2011
4.
4.
4.
O O
4.
5.
6.
7.
Regular
STP
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4.
5.
6.
7.
Super
STP
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