HomeMy WebLinkAbout2010 FMC RESULTS1212012010 10:16 IFAX EH @C0.KERN.0A.US + Dept Main ? 001/00412/20/2010 10:02 6616349233 KERN CONSTRUCTION PAGE 01/04
MONITORING SYSTEM CERTIFICATION
For Use By All Jurisdictions ithin the ,State ofCalifornia
Authority Cited: Chapter 67, Health and Safety Code; Chapter 16, Division 3, Pile 23, California Code ofRegulations
This form must be used to document testing and servicing of monitoring equipment, A separate ecitificatig» err report muqLbe pre d for eagh
mo itori g gy-stc nn cogt a el by the technici?n who performs the work. A copy ofthis form must be provided to the tank.tyetem owner /operator,
Titc owner /operator must submit a copy of this form to the local agency regulating TJST systems within 30 days of test date.
A. General Information
Facility Name: -- i m'-<, I"100-1 L- _ Bldg, No,:,_
Site Address: _ 2IC) E 22E- City: r Z zip:
Facility Contact Peron. Contact Phone No.: ((L-
Make/Model ofMonitoring System: 7-,5 50 [late of Testing /Servicing: /2--
S. Inventory of Ltluipment Tested /Certified
Tnnlc 11A: ul r_ EV Sy`-
i9in -Tohk Gauging Probe. Model:
Annular Space or Vault Sensor, Model;
Piping Sump / Trench Sctoor(s). Model:
Fill Sump Settsor(s). Model;
1] Mechanics) Line Leak Detector. Model:
Electronic Lino Leak Detector, Model;
Tank Overfill t High -Level Sensor. Model;
Other fsrxeifv couiomcnt tvoe and model in Section E on Paae 21,
Tank[?): 7 t•rsiS tQN (t! -d
Tn•Tnnk Gouging Probe,
rf7
Model:
Annuity Spacc or Vault Senimr. Modci:
piping Sump I'hrench Somogs). Model; ye— ze8
Fi11 Sump Scnsor(a). Model;
0 Mechanical Lino l mkDetector, Model:
Electronic Line Lcak Detector, Model-
IJ Tank Ovcrnll / High-Level Sensor, Model:
Other (.gpcc4 equipment type and model in Section E on Page 2).
Tank ID: ZZ f 2r 1'uM
Rjo -Tank Gauging Pm c, Model: /fr /
Annular Space or Vault Sensor. Model:
PipitiF Sump / Trench Sensor(s), Mcxlcl;
0 Fill Sump Sensor(s), Model:
Mechanical Line Leak Detator. Model;
Electronic Lino Leak Dctectnr, Model:
Tank, Overfill / High -Level Set ,snr, Model:
other (specify equipment type and model in Section B on Pngc 2).
Tank TO
0 In -Tank Gauging Probe, Model:
0 Annular Space or VRult Scnsor, Model:
0 Piping Sump / Trench Sonsor(s), Model:
Fill Sump Seruor(s). Model:
Mcehanical Tjnc T"k Detector. Model:
Electronic Una t.,oRk Detector. Model:
Q Tank Overfill / Hig,- 1,cvcl 9cnnor, Model:
Other (specify equipment typo end model in Section E on Pngc 2).
Dispenser TO; —t —Z- Dispenser.TD: 7 —5'
P4 T)i.gpcnncr Containment Scnsor(s). Model: 4f- nip 4&C- _ C3 DispcnRcr Corltalnment Sonsor(s), Modci; < ,4-/eV-
M,Shcar VRIVC(5). 13 t' - l f.Shear Valvc(s).
DitNnaor Contifntnent Flnmgs) and Chain(s). Q INspenser Containment Flont(s) and Chaln(s),
Dispenser TD:
LZ Dispenser Containment Sensor(s), Model:
IZ shear Valve(s),
1l Dispenser Containment Float(s) and Chain(s),
Dispenser ID: / ^ %O
T)ispcnser Containmem Sonsor(s), Model: 51?WC> A4oryi-
ShearWvc(s). r jQG1
Dispenser Containment Floot(s) and Chain(s).
Dispenser TD: 'jj- (o Dispenser TD:
DrspcnserContainmcntSengeKs), Model! (DispcnscrContainmentScnsor(s), Model: d
Shear Volvo($), I30 -hLlj Shcar Valvc(s).
Dispenser Containment Float(i) and Chnin(s). Dispenser Containment Fioot(s) and Chain(s),
Tfthe facility contains more tanks or dispensers. copy this form. Include information for every tank and dispenser at the facility
C. Certification - t certify that the equipment identified in this document wrts inspected /serviced in accordance with the
manuftw0trem' gaidelines, Attached to this Certification is information (e.g. manafneturem' cheekiisLq) necessary to verify that this
information is correct and a Plot plan showing the i>.yont nT monitoring equipment. For any equipment capable of general3ng such
reports, I have also attached .9 copy of the report; rcheck all Mat Opp/))., $Stem net ( A1Arm ltigto report
Technician Name (print): Signature: ,rr
Certification No.: dZ - l7' License. No.: -
Testing Company Name: fjrnrtf Phone No,: Lj:(d /) 6 5p
Testing Company Address; _- -- Date of Testing/Scrvicing: /-?nn-—
TIN.036 - 114
Page 1 of 4
www.unidncs.ort; Rev. 01/170
12/20/2010 10:16 IFAX EHHOJERN. CA. US
12/20/2010 10 :02 6616349233
Monitoring System Certiiicntion
1). Results of Testing/Servicing
Software Version installed: JG r
i Dept Main ? 002/004
KERN CONSTRUCTION PAGE 02/04
In Section F below, describe how and when these deficiencies were or will be corrected.
F. Comments:
Page 2 of 4
UN -036 - 2/4 WWW.nnidomarc Rev. 01/17/08
F
y
12/20/2010 10:16 IFAX EH @C0.KERN.CA.US
12/20/2010 10:02 6616349233
Monitoring System Certifie9tion
i Dept Main 12003/004
KERN CONSTRUCTION PAGE 03/04
F. Tn -Tank Gauging/ SIR Equipment: Check this box iftank 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:
L'3t'Yes No* Has all input wiring been inspected for proper entry and termination, including testing for ground faults?
XYes 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 ofsystem water level readings tested?
Yes No* Were all probes reinstalled properly?
j Yes No* Were all items on the equipment manufacturer's maintenance checklist completed?
In Section H, below, describe how and when tnese aeneteneie.R were ur win uc currecLuu.
G. Tine Leak Detectors (LLD): Check this box if LLDs are not installed.
vv v[
I For equipment start -up or annual equipment certification, was a leak simulated to verify LLD performance?
Check all that apply) Simulated leak rate: IBI 3 g.p•h.; 0.1 g.p.h ; 0.2 g.p.h.
Yes No*
v
NIA
Yes No* Were all LLDs confirmed operational and accurate within regulatory requirements?
Yes No* Was the testing apparatus properly calibrated?
Yes No*
XN /A
For mechanical LLDs, does the LLD restrict product flow if it detects a leak?
Yes No*
N/A
ror electronic LTAX does the turbine automatically shut offif the LLD detects a leak?
Yes No*
N/A
For electronic LLDs, does the turbine automatically shut off if any portion ofthe monitoring system is disabled
or disconnected?
Yes No*
N/A
For electronic LLDs. does the turbine automatically shut off if any portion of the monitoring system
malfunctions or fails a test'?
Yes No*
A
For electronic LLDs, have all accessible wiring connections been visually inspected?
Yes No* I 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 4
www.Uni(lovLarg Rev. 01/17/08
12/20/2010 10:16 IFAX EH@CO.KERN.CA.US + Dept Main ? 004/004
12/20/2010 10:02 6616349233 KERN CONSTRUCTION PAGE 04/04
SWRCl3, Januai-y 2()()6
Spill Bucket Testing Report Form
Thisjbrtn is intendedfor use by contractors performing annual resting oj' UST spill wmaintriptitsirurtures. the eomple-ti4form and
printouts from 1&ts (if (IPI)Iical)lop,), should baproi4dedtn 0wfbcility owner /operatorfor submittal to the local regulatory agency,
I- FAM,TTVYNFnRMAT'10N
FaciI i ty Namc: L
Test
Test Equipment Used:
I- Date afr;stin-, 12 70—
Fot,iliry Address; 700
Facility7 . C0.11.1act.
Date Local Agency Was Notified ofTesting
1
1441
f
Nanit, of Local Agency Inspector (ifpresent during testing):
3
2. TES11ING CONTRACTOR INFORMATION
Conipony Na
Tu-Imician Condiicting!Test;
Credential-': F1 CS•R Contractor gICC Service Tech. SWROB TankTcsftt- 02Lber Specify),
Liceiisr Number(s)A, (FD
Z qPYT.1, RTTC'TC'V.I' TF.qTTNr. INFORMATION
Z, 171) —Mi Used; (K-lydanstatic 11 Vacuum—"-.— 0 OtherTest
Test Equipment Used: Equipment Resolution:
ldemiCy Spill Bucket (!3v Tank
Number, Stored Product. etc.)
1
1441
f 2 3 4
BLICk-Er Installation Type; A Direct )all.-Y
Contained in Sump
kbirect Bury
F1 Contained. jS Su
Direct Bury
Contained in Sutter_
Direct Bury
Contained in Stunp
Bucket Diivmeter: 12 12
Bucket Depth; 14
Wait orne between applying
lcullinAvater'.) nd Start oftest: 30 Hw WI-(mi
Tcst St,,trtTjme. (Ti);
tnifi;.11 Reading (Rj):
Test, J311d "I'vae, 0'r). rQ q
Readiag (1'.F):
Test Dw:alim (TIz - Tj):
Chan ,o iD, Rennin R. - Rj);
r Pass/1"ail Threshold or
TeStResulti o"nss Vail AP,L49 OFail Pass 0 Fail 0 Pass 0 Fail.
C01I'l. - (include iitforniation on repairs made prior to testing, and recommendedfollow -upforfailed tests)
CERTIFICATION OF T-FCT-1WTC'JAN RESPONSIRLT. FOR CONDUCTYNG THIS TESTING
I herelly certify that all the infSCvzqion rantained in this report is trite, accuraV!, and iftfull compliance with legal requirements,
Technician's sigrulturL. Date:
State laws and regulations do not currently require testing to be performed by a qualified coatnetor. However, local reqLLir0r11CUt,-,
may be Inore m.H.Iigelit.