HomeMy WebLinkAbout11101 178 HWY (7)MONITORING SYSTEM CERTIFICATION
Pa55
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 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 this date.
A. General Information
Facility Name: Mesa Marin Food Mart
Site Address: 11101 Highway 178 City: Bakersfield
Facility Contact Person: Moe
Make /Model of Monitoring System: Veeder -Root TLS 350
B. Inventory of Equipment Tested /CertifiedChecktheappropriateboxestoIndicatespecificequipmentinspectediserviced:
Bldg. No.:
Zip: 93306
Contact Phone No.: 661 - 3664886
Date of Testing/Servicing: 01/4/2012
Tank ID: 10000 gal. Regular Tank
x]
ID: 10000 gal. Plus
In -Tank Gauging Probe. Model: 847390 -107UIn -Tank Gauging Probe. Model: 847390-107
Annular Space or Vault Probe. 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:
X] Electronic Line Leak Detector. Model: WPLLD U Electronic Line Leak Detector. Model: WPLLD
x] Tank Overfill / High Level Sensor. Model: 847390 -107 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: 10000 gal. Super Tank ID: 10000 gal. Diesel
x] In -Tank Gauging Probe. Mode1:847390-107 x] In -Tank Gauging Probe. Model: 847390 -107
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 Detector. Model: Mechanical Line Leak Detector. Model:
x] Electronic Line Leak Detector. Model:WPLLD x] Electronic Line Leak Detector. Model: WPLLD
x] Tank Overfill / High Level Sensor. Model: 847390-107 x] Tank Overfill / High Level Sensor. Model: 847390 -107
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 8t 2 Dispenser ID: 3 8t 4
Dispenser Containment Sensor(s). Model: Dispenser Containment Sensor(s). Model:
X] Shear Valve(s). x] Shear Valve(s).
x] Dispenser Containment Float(s) and Chain(s). X] 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 Chains(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 -1 certify that the equipment identified in this document was inspected /seryices 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 of the report; (check all that apply) x System Set -up x] Alarm his ry report
Technician Name (print): Bradley Seykora Signature:
Certification No: B40738 License No: 80490
Testing Company Name: Confidence UST Services, Inc. Phone No: 800 - 339 -9930
Site Address: 11101 Highway 178, Bakersfield, CA 93306 Date of Testing/Servicing: 0114/2012
D. Results of Testing /Servicing
Software Version Installed: 14.00
Complete the following checklist:
Lx] Yes No* Is the audible alarm operational?
rxj Yes No* Is the Visual alarm operational?
Yes F I No* Were all sensors visually inspected, functionally tested, and confirmed operational?
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?
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? Sump /Trench Sensors El 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
II 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? 90 %
Yes* F_ 1 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.
U Yes* No Was liquid found inside any secondary containment systems designed as dry systems?
Product; Fxl Water. If yes, describe causes in Section E, below.
x No* Was monitoring system set -up reviewed to ensure proper settings? Attach set -up reports, if applicable.
Lx_J Yes 10 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:
Roughly 15 gallons of water was removed from the diesel STP.
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 termination,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?
Fxj 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:
x 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: [x]3 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 D No* Was the testing apparatus properly calibrated?
Yes No* For mac amcal LLD's, does the LLD restrict product flow if it detects a leak?
x N/A
x] Yes No* For electronic LLD's, does the turbine automatically shut off ifthe LLD detects a leak?
N/A
Lx] Yes No* For electronic LLD's, does the turbine automatically shut off if any portion of the monitoring system is
N/A disabled or disconnected?
rx] Yes No* For electronic LLD's, does the turbine automatically shut off if any portion of the monitoring system
N/A malfunction or fails a test?
Yes No* For electronic LLD's, have all accessible wiring connections been visually inspected?
N/A
Lxj Yes No I 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:
HFsH I-IHRI 1-1
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13986 3986
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OVERFILL LIMIT 90., 9,195 9.1135
8986 DELIVERY LIMIT Mi. DELIVERY L I FI I T 10",:,
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985
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LOW F'RODLb:'T 500 TANK. TILT 0.20 TANK TI LT I .04
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Two, T I LT 0.::t0 TN : NONE TO: NONE
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WiTER WARN MC. 2.0
I-1101 WATER LIMIT: 3.0
PVA* * QP LMREL VOL: 99935
OVERFILL I.Iiill' 9tr,
8966
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LAW PRoril le'l, 500
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VOLIAIE 0748 :;iiLS
WATER 0.84 INCHES
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Pi-;I*F;,PS*FIEI b,C*o 94306
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28 17 o4l-S
VOLUME . 541 1 L.--',
ULLAC,E = w37,i :;iiLS
90% LILLit;E= a576 i:-';ALS
D.- VIOLIVIE = 5376 t' ,;LS
HE 11.; HT = 50.51 1 fir-11ES
WATER VOL - ri CALS
LIHTER . 0.110 1 NCHES
TDIP . 69 . 1 1. 11 _*., G F
T 2: D I
28 17 o4l-S
ULIAGE .
VOLUME 3441" t:;ALS
ULU-iC-E n r.64
90". ULLAC.E 5044
0 G' LS
TC VOLUME - 3921 f.ALS
HEIGHT - 39. 5t INCHES
WATER VOL - 12 GALS
L• . 0.77 1 NCHES
TEMP . 70. 1) DEC., F
T 3: SUPER LINUAlEl'.1
VOLUME . 28 17 o4l-S
ULIAGE . 716u
9(Al, LJI-Lmi*;L:- 61 c,9 43441-S
TC- VOLLIHE - 2713';, 13o.,I.S,
srj. 66 1 NO-IFSJ.66
VOL 0 G' LS
WmTER . U. Of's I NO IES
TEMP . 71 . C, DEC; )-'
r 4 : Puip,
VOLUME . 2830 r;tiLS
ULL.ol:;E . 7l 55
SIM 6 156 1: L,.-,
ri: vouoc z 266'? -, HI -s
HE I C.'H,r - 30. 14 C. I NrlIES
IthM-*Il`,' VOL 1-1 C;MLS
WATER . U. 011 1 PC: I I ES
TEMF' . ?1 .5 r-EG F
x P* .. 4 1714D - , -z :.
SWRCB, January 2006
Spill Bucket Testing Report Form
Thisform is intendedfor use by contractors performing annual testing of UST spill containment structures. The completedform and
printoutsfrom tests (fapplicable), should be provided to thefacility owner /operatorfor submittal to the local regulatory agency.
1. FACILITY INFORMATION
Facility Name: Mesa Marin Food Mart I Date of Testing: 1/4/2012
Facility Address: I 1 101 Highway 178, Bakersfield, CA 93306
Facility Contact: Moe I Phone: 661 - 366 -4886
Date Local Agency Was Notified of Testing: 12/7/2011
Name of Local Agency Inspector (fpresent during testing): Ernie Medina
2. TESTING CONTRACTOR INFORMATION
Company Name: Confidence UST Services, Inc.
Technician Conducting Test: Bradley Seykora
Credentials': X CSLB Contractor X ICC Service Tech. SWRCB Tank Tester Other (Spec)
License Number(s): CSLB #804904 ICC # 8111231
3. SPILL BUCKET TESTING INFORMATION
Test Method Used: x Hydrostatic Vacuum Other
Test Equipment Used: Lake Test Equipment Resolution: .0625"
Identify Spill Bucket (By Tank
Number, Stored Product, etc.
1 Regular 2 Plus 3 Super 4 Diesel
Bucket Installation Type: x Direct Bury
Contained in Sump
x Direct Bury
Contained in Sump
x Direct Bury
Contained in Sump
x Direct Bury
Contained in Sum
Bucket Diameter: 12.00" 12.00" 12.00" 12.00"
Bucket Depth: 15.00" 14.75" 14.00" 14.00"
Wait time between applying
vacuum /water and start of test: 5 min. 5 min. 5 min. 5 min.
Test Start Time (Ti): 9:30 am 9:30 am 9:30 am 9:30 am
Initial Reading (111): 8.75" 8.50" 9.00" 9.75"
Test End Time (TF): 10:30 am 10:30 am 10:30 am 10:30 am
Final Reading (RF): 8.75" 8.50" 9.00" 9.75"
Test Duration (TF — Tj): 1 hour 1 hour 1 hour 1 hour
Change in Reading (RF - Ri): 0.00" 0.00" 0.00" 0.00"
Pass /Fail Threshold or
Criteria: 0625" 0625" 0625" 0625"
Test Result: X Pass Fail X Pass Fail X Pass Fail X Pass Fail
Comments — (include information on repairs made prior to testing, and recommendedfollow -upfor jailed tests)
CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING
I hereby certify that all the information contained in this reportis true, accurate, and infull compliance with legal requirements.
Technician's Signature: Date: 1/4/2012
State laws and regulations do not currently require testing to be performed by a qualified contractor. However, local requirements
may be more stringent.
1= Gilbarco EMC
2= Overfill Alarm
3= ESO Switch
4= ATG
5= Regular Turbine
6= Plus Turbind
7= Super Turbine
8= Diesel Turbine
9= Bravo Box
10= PLLD
Mesa Main CHevron & Food
Mart, 11101 Highway 178
Bakersfield, .CA 93306
1/24/2011
Lj
5,10 8,10 7,10 6,10
O O O4 4O
O OO
O
O O O
Regular Fill Diesel Fill Super Fill Plus FillDirectBurialDirectBurialDirectBurialDirectBurial