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Home My WebLink AboutFMC RESULTS 2016UN-036 – www.unidocs.org Rev. 01/17/08 MONITORING SYSTEM CERTIFICATION For Use By All Jurisdictions Within the State of California 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 test date. A. General Information Facility Name: American Gas Bldg No.:N/A Site Address: 402 South Chester Ave. City:Bakersfield, Ca. Zip:93204 Facility Contact Person: Nick Nickakhtar Contact Phone No.: (805) 479-8564 Make/Model of Monitoring System: Veeder Root TLS-350 Date of Testing/Servicing:12/14/16 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced: Tank ID: T-1 87 Tank ID:T-2 91 In-Tank Gauging Probe. Model: VR-Mag 1 In-Tank Gauging Probe. Model: VR-Mag 1 Annular Space or Vault Sensor. Model: VR-420 Annular Space or Vault Sensor. Model: VR-420 Piping Sump / Trench Sensor(s). Model: VR-208 Piping Sump / Trench Sensor(s). Model: VR-208 Fill Sump Sensor(s). Model:  Fill Sump Sensor(s). Model:  Mechanical Line Leak Detector. Model: RJ FX-1V Mechanical Line Leak Detector. Model: VMI LD-2000 Electronic Line Leak Detector. Model:  Electronic Line Leak Detector. Model:  Tank Overfill / High-Level Sensor. Model: OPW Flapper Valve Tank Overfill / High-Level Sensor. Model: OPW Flapper Valve Other (specify equipment type and model in Section E on Page 2). Other (specify equipment type and model in Section E on Page 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 Sensor(s). Model:  Fill Sump Sensor(s). Model:  Mechanical Line Leak Detector. 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 equipment type and model in Section E on Page 2). Other (specify equipment type and model in Section E on Page 2). Dispenser ID: # 1-2 Dispenser ID:# 3-4 Dispenser Containment Sensor(s). Model: VR 001 Dispenser Containment Sensor(s). Model: VR 001 Shear Valve(s).  Shear Valve(s).  Dispenser Containment Float(s) and Chain(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). 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 - 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; (check all that apply): System set-up Alarm history report Technician Name (print): RICHARD THOMAS Signature: Certification No.: B34022 License. No.:803616 Testing Company Name: CGRS, Inc. Phone No.:916-991-1100 Testing Company Address: 5444 Dry Creek Rd. Sacramento, CA 95838 Date of Testing/Servicing:12/14/16 Page 1 of 4 Monitoring System Certification UN-036 – www.unidocs.org Rev. 01/17/08 D. Results of Testing/Servicing Software Version Installed: 333.06 Complete the following checklist: Yes No* Is the audible alarm operational? Yes No* Is the visual alarm operational? Yes No* Were all sensors visually inspected, functionally tested, and confirmed operational? Yes No* Were all sensors installed at lowest point of secondary containment and positioned so that other equipment will not interfere with their proper operation? Yes No* N/A If alarms are relayed to a remote monitoring station, is all communications equipment (e.g., modem) operational? Yes No* N/A For pressurized piping systems, does the turbine automatically shut down if the piping secondary containment monitoring system detects a leak, fails to operate, or is electrically disconnected? If yes: which sensors initiate positive shut-down? (Check all that apply) Sump/Trench Sensors; Dispenser Containment Sensors. Did you confirm positive shut-down due to leaks and sensor failure/disconnection? Yes; No. Yes No* N/A For tank systems that utilize the monitoring system as the primary tank overfill warning device (i.e., no 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 of tank capacity does the alarm trigger? % 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* No Was liquid found inside any secondary containment systems designed as dry systems? (Check all that apply) Product; Water. If yes, describe causes in Section E, below. Yes No* Was monitoring system set-up reviewed to ensure proper settings? Attach set up reports, if applicable Yes 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: 1. Disp. # 1-2 & # 3-4 have Veeder Root 001 “Stand Alone” sensors installed for primary leak detection. Sensors only remove power at dispenser when in active alarm state. Page 2 of 4 Monitoring System Certification UN-036 – www.unidocs.org Rev. 01/17/08 F. In-Tank Gauging / SIR Equipment: Check this box if tank 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: Yes No* Has all input wiring been inspected for proper entry and termination, including testing for ground faults? Yes 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 of system water level readings tested? Yes No* Were all probes reinstalled properly? Yes No* 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. G. Line Leak Detectors (LLD): Check this box if LLDs are not installed. Complete the following checklist: Yes No* N/A For equipment start-up or annual equipment certification, was a leak simulated to verify LLD performance? (Check all that apply) Simulated leak rate: 3 g.p.h.; 0.1 g.p.h ; 0.2 g.p.h. Yes No* Were all LLDs confirmed operational and accurate within regulatory requirements? Yes No* Was the testing apparatus properly calibrated? Yes No* N/A For mechanical LLDs, does the LLD restrict product flow if it detects a leak? Yes No* N/A For electronic LLDs, does the turbine automatically shut off if the LLD detects a leak? Yes No* N/A For electronic LLDs, does the turbine automatically shut off if any portion of the 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* N/A For electronic LLDs, have all accessible wiring connections been visually inspected? Yes No* 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: 1. T-2 91 RJ FX-1V LD failed 3 consecutive tests, replaced and retested with VMI LD-2000 and passed. Page 3 of 4 Monitoring System Certification K. Float and Chain Equipment: Check this box if floats and chains are not present at this site. Check this box if float and chain equipment is installed but only as secondary leak detection. This section must be completed if floats and chains are used to perform leak detection monitoring. Complete the following checklist: Yes No* Were all float and chain equipment properly inspected and tested for correct functionality? Yes No* Were all float and chain equipment certified to be working properly? * In the Section M, below, describe how and when these deficiencies were or will be corrected. L. Impact Valves: Check this box if impact valves are not installed. Complete the following checklist: Yes No* Were all impact valves properly inspected and tested for correct functionality? Yes No* Were all impact valves certified to be working properly? * In the Section M, below, describe how and when these deficiencies were or will be corrected. M. Comments: Page 5 of 5 SWRCB, January 2006 Spill Bucket Testing Report Form This form is intended for use by contractors performing annual testing of UST spill containment structures. The completed form and printouts from tests (if applicable) should be provided to the facility owner/operator for submittal to the local regulatory agency. 1. FACILITY INFORMATION Facility Name: American Gas Date of Testing: 12/14/16 Facility Address: 402 South Chester Ave., Bakersfield, Ca. 93204 Facility Contact: Nick Nickakhtar Phone: (805) 479-8564 Date Local Agency Was Notified of Testing: via email 12/12/16 @10:04 am Name of Local Agency Inspector (if present during testing): Shane Gardner @ Bakersfield F.D. 2. TESTING CONTRACTOR INFORMATION Company Name: CGRS, Inc. Technician Conducting Test: RICHARD THOMAS Credentials1: CSLB Contractor ICC Service Tech. SWRCB Tank Tester Other (Specify) License Number(s): 803616 (CSLB Contractor) -- 5297888-UT (ICC Service Tech.) -- 06-1672 (SWRCB Tank Tester) 3. SPILL BUCKET TESTING INFORMATION Test Method Used: Hydrostatic Vacuum Other (Specify) Test Equipment Used: Tape Measure Equipment Resolution: +or- 1/16” Identify Spill Bucket (By Tank Number, Stored Product, etc.) 87 Fill 91 Fill Bucket Installation Type: Direct Bury Contained in Sump Direct Bury Contained in Sump Direct Bury Contained in Sump Direct Bury Contained in Sump Bucket Diameter: 12” 12” Bucket Depth: 12 ¾” 13” Wait time between applying vacuum/water and start of test: 10 min 10 min Test Start Time (TI): 8:40am 8:40am Initial Reading (RI): 12 ¾” 13” Test End Time (TF): 9:40am 9:40am Final Reading (RF): 12 ¾” 13” Test Duration (TF – TI): 1 hr 1 hr Change in Reading (RF - RI): 0” 0” Pass/Fail Threshold or Criteria: No Loss No Loss Test Result: Pass Fail Pass Fail Pass Fail Pass Fail Comments – (include information on repairs made prior to testing, and recommended follow-up for failed tests) 1. Vapor Buckets not tested, only to be tested every 3yrs on SB-989 testing. 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: 12/14/16 1 State laws and regulations do not currently require testing to be performed by a qualified contractor. However, local requirements may be more stringent. PRESSURIZED PIPING LEAK DETECTION CERTIFICATION SHEET Date: 12/14/16 Work Order #N/A Location: American Gas Contact:Nick Nickakhtar 402 South Chester Ave. Bakersfield,Ca. 93204 Telephone:(805) 479-8564 SUMP # #3-4 #3-4 #3-4 PRODUCT 87 91 91 LD TYPE [ (M)echanical, (W)PLLD, (P)LLD ] M M M LD MANUFACTURER Red Jacket Red Jacket VMI LD MODEL FX-1V FX-1V LD-2000 LD SERIAL NUMBER 30805-4716 30112-7528 16051030 SUMP CONDITION Dry Dry Dry RESILIENCY 250ml 500ml 500ml OPERATING PRESSURE 25 PSI 24 PSI 24 PSI OPENING TIME 4 seconds 0 seconds 4 seconds METERING PRESSURE 10 PSI 10 PSI 10 PSI FUNCTIONAL ELEMENT HOLDING PRESSURE 16 PSI 16 PSI 16 PSI LEAK RATE LD DETECTED 3 GPH 3 GPH 3 GPH DOES LD DETECT 3 GPH LEAK RATE? Yes No Yes DOES VEEDER-ROOT CONSOLE ALARM? N/A N/A N/A LD PASS OR FAIL? Pass Fail Pass Comments: 1. T-2 91 LD failed 3 consecutive test, replaced with VMI LD-2000. 2. T-2 91 Fe-Petro syphon leak jet showing signs that it may need to be replace in the near future. Technician: RICHARD THOMAS Contractor Lic. # 803616 Signature: