HomeMy WebLinkAbout2012 RESULTSMONITORING 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 ofthis form to the local agency regulating UST systems
within 30 days ofthis date.
A. General Information
Facility Name: #346 Fastrip #621
Site Address: 805 34th Street
Facility Contact Person: Omero Garcia
Make/Model of Monitoring System: Gilbarco EMC
B. Inventory of Equipment Tested /Certified
Check the appropriate Mes to indicate specific equipment Inspected /seroced:
Bldg. No.:
City: Bakersfield Zip: 93301
Contact Phone No.: 661 - 393 -7000
Date ofTesting/Servicing 06/11/2012
Tank ID:_12000 gal. Regular 1 Tank ID: 12000 gal. Regular 2
x] In -Tank Gauging Probe. Model: 847390 -107 x] In -Tank Gauging Probe. Model: 847390 -107
x] Annular Space or Vault Probe. Model: 794390 -420 x] Annular Space or Vault Sensor. Model: 794390 -420
x] Piping Sump / Trench Sensor(s). Model: 794380 -208 x] Piping Sump / Trench Sensor(s). Model: 794380 -208
Fill Sump Sensor(s) Model: Fill Sump Sensor(s). Model:
x 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: 12000 gal. Super Tank ID: 12000 gal. Diesel
x] In -Tank Gauging Probe. Model: 847390-107 Lx] In -Tank Gauging Probe. Model: 847390 -107
x] Annular Space or Vault Sensor. Model: Ronan x] Annular Space or Vault Sensor. Model: 794390 -420
x] Piping Sump / Trench Sensor(s). Model: 794380 -208 L] Piping Sump / Trench Sensor(s). Model: 794380 -208
Fill Sump Sensors(s). Model: Fill Sump Sensor(s). Model:
x Mechanical Line Leak Decector. Model: FX1V x] Mechanical Line Leak Detector. Model: FX1 DV
Electronic Line Leak Detector. Model: F-1 Electronic Line Leak Detector. Model:
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 $ 2 Dispenser ID:_3 $ 4
x_. Dispenser Containment Sensor(s). Model: 794380 -208 z] 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
x] Dispenser Containment Sensor(s). Model: 794380 - 208 X] Dispenser Containment Sensor(s). Model: 794380 -208
U Shear Valve(s). x] Shear Valve(s).
Dispenser Containment Float(s) and Chains(s). Dispenser Containment Float(s) and Chain(s).
Dispenser ID: Trans. East Dispenser ID: Trans. West
X] 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).
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 /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, 1 have attached a copy of the report; (check all that apply) System Set -up fx] Alarm history report
Technician Name (print): Kristopher Karns Signature:
Certification No: B34106
Testing Company Name: Confidence UST Services, Inc.
Site Address: 805 34th Street , Bakersfield, CA 93301
License No: 804904
Phone No: 800 - 339 -9930
Date of Testing/Servicing: 0611112012
D. Results of Testing /Servicing
Software Version Installed: 329.02
Complete the following checklist:
x] Yes No* Is the audible alarm operational?
x Yes I No* Is tfie—Visual alarm operational?
x Yes No* Were all sensors visually inspected, functionally tested, and confirmed operational'?
Ix 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'?
Yes No* If alarms are relayed to a remote monitoring station, is all communications equipment (e.g. modem) Hx N/A operational?
T 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;
X] Yes No* For tank systems that utilize the monitoring system as the primary tank overfill warning device (i.e. no
r ] 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? IfYes, 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.
TX No* Was monitoring system set -up reviewed to ensure proper settings? Attach set -up reports, if applicable.
Lxj Yes No* 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: Replaced the light bulb on the Exterior overfill alarm.
Replaced the Super 420 Annular Sensor, because the original was not operational. Once the new sensor was installed it was
retested and confirmed operational.
I also replaced the Super FXI V Line Leak Detector, because the original was unable to detect a leak of 3 GPH @ 10 PS1. Once
the new FXI V was installed, it was retested and confirmed operatinal.
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 tennination,including testing for ground faults?
Yes3p No* Were all tank guaging probes visually inspected for damage and residue buildup?
xx
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'?
E Yes I 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.
G. Line Leak Detectors (LLD):
Complete the following checklist:
Check this box if LLD's are not installed.
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.; 0.2 g.p.h.;
M Yes No* Were all LLD's confinned operational and accurate within regulatory requirments?
x Yes No* Was the testing apparatus properly calibrated'?
es No For mac amca LLD's, does the LLD restrict product flow if it detects a leak'?
N/A
Yes I 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 if any portion of the monitoring system is
x] N/A disabled or disconnected?
Yes No* For electronic LLD's, does the turbine automatically shut off if any portion of the monitoring system
rx] N/A malfunction or fails a test?
Yes No* For electronic LLD's, have all accessible wiring connections been visually inspected'?
Lx] N/A
x 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.
H. Comments:
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SWRCB, January 2006
Spill Bucket Testing Report Form
This form is intendedfor use by contractors performing annual testing of UST spill containment structures. The completedform and
printouts from tests (if applicable), should be provided to thefacility owner /operatorfor submittal to the local regulatory agency.
1. FACILITY INFORMATION
Facility Name: #346 Fastrip #621 Date of Testing: 06/11/2012
Facility Address: 805 34' Street , Bakersfield, CA 93301
Facility Contact: Omero Garcia Phone: 661- 393 -7000
Date Local Agency Was Notified ofTesting : 5/11/2012
Name of Local Agency Inspector (fpresent during testing): Ester Duran
2. TESTING CONTRACTOR INFORMATION
Company Name: Confidence UST Services, Inc.
Technician Conducting Test: Kristopher Karns
Credentials: X CSLB Contractor X ICC Service Tech. X SWRCB Tank Tester Other (Specify)
License Number(s): CSLB #804904 ICC #5264406 -UT SWRCB # 09 -1743
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 1 2 Regular 2 3 Super 4 Diesel
Bucket Installation Type: Direct Bury
x Contained in Sump
Direct Bury
x Contained in Sump
Direct Bury
x Contained in Sump
Direct Bury
x Contained in Sum
Bucket Diameter: 12.00" 12.00" 12.00" 12.00"
Bucket Depth: 14.25" 14.50" 13.75" 14.00"
Wait time between applying
vacuum /water and start of test: 5 min. 5 min. 5 min. 5 min.
Test Start Time (T,): 9:00 am 9:00 am 9:00 am 9:00 am
Initial Reading (Rj): 10.25" 10.75" 10.00" 10.50"
Test End Time (T,:): 10:00 am 10:00 am 10:00 am 10:00 am
Final Reading (RF): 10.25" 10.75" 10.00" 10.50"
Test Duration (TF — T,): 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: 0.0625" 0.0625" 0.0625" 0.0625
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 -upforfailed testa)
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 requirements.
Technician's Signature: Date: 06/11/2012
State laws and regulations do not currently require testing to be performed by a qualified contractor. However, local requirements
may be more stringent.
I ,
ii
6
4
3 '
6'7'9
i
19 4;6,7,10
14-
15 4,6,7,11
0 4,6,8,1216
Fastnp # 3346
805 34th Street
Bakersfield, CA 93301
6/11/2012
1= Gilbarco EMC
2= External Overfill Alarm
3= Emergency Shut Off Switch
4= Veeder Root ATG Probe
5= Veeder Root 420 Annular Sensor
6= Veeder Root 208 Sump Sensor
7= Red Jacket FX IV Line Leak Detector
8= Red Jacket FX 1 DV Line Leak Detector
9= 12000 Gallon Regular 1 STP Sump
10= 12000 Gallon Regular 2 STP Sump
11= 12000 Gallon Super STP Sump
12= 12000 Gallon Diesel STP Sump
13= Regular 1 Fill Sump
14= Regular 2 Fill Sump
15= Super Fill Sump
16= Diesel Fill Sump
17= Transition Sump East
18= Transition Sump West
19= Ronan Annular Sensor
0
IDF
U
Job Order/ Invoice # a9(:7`4
COMPLIANCEWITH CONFIDENCE'
Date Call Made Time To Whom Station Control Number Repair Date Invoice Date8TollFree #: 1 -500- 339 -9930
cl -la
Name Confidence UST Services, Inc. Site Name: *334- i AST2l
s` Street 16250 Meacham Road o Street X05WA
City Bakersfield,Ca 93314 City Stat Zip o
01
Terms rnoTo2 lr c rZTt tCRT Store Number:
Description of work performed:
aLTN,n,,lril RL L D/,I PAi -v To 120 ,D(a C- iA/
Il RNr ul g12_ tGl1 %Ct lL t 5 t? X l / -r- -i l z -i C(y /2 . ! H II
I o tea., L u
Labor
Date Name /Number Class Hours
RateArrivedDepartedLaborTravelTotal
Il t 2LS
5,4
t ei= PM PM L O
lt9•
Total C Mileage
AM
PM
AM
PM
Total Amount
Invoice A + B + C
4
AM AM
X I I I PMI PMI
Contractor Supplied - Materials - Rentals Amount Sub -Total
Quantity
Total A Labor 14(p • Z5
t Fx t Urf 5,4 Total B Material qq • a,,,'
46
Total C Mileage
Total Amount
Invoice A + B + C
4
Accounting Breakdown
Mileage
Miles Rate Total Sub Total
Handling %
Tax ( If applicable)
Total C Total B cA , 2_11
May we please have your comments regarding service / equipment provided by the above named contractor:
Store Employee Printed Nam /
i
Store Em ignatureye Date
lob-
Approve Date
V