HomeMy WebLinkAboutFMC RESULTS 2016 (2)MONITORING SYSTEM CERTIFICATION
For Use By All Jurisdictions Within the State of CaliforniaAuthority 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:Bldg. No.:
Site Address:City:Zip:
Facility Contact Person: Contact Phone No.:
Make/Model of Monitoring System:Date of Testing/Servicing:
B.Inventory of Equipment Tested/Certified
Check the appropriate boxes to indicate specific equipment inspected/serviced:
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 LineLeak 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).
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 / TrenchSensor(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: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).
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):Signature:
Certification No.:License. No.:804904
Testing Company Name:Confidence UST Services, Inc.Phone No.:(800)339-9930
Site Address:Date of Testing/Servicing:
Page 1 of 3
MesaMarinChevron
11101Highway178Bakersfield93306
MohammudMuthana (661)366-4886
Veeder-RootTLS-350
10,000gal.Regular
847390-107
PLLD
847390-107
10,000gal.Plus
847390-107
PLLD
847390-107
10,000gal.Super
847390-107
847390-107
10,000gal.Diesel
847390-107
PLLD PLLD
847390-107
1-2 3-4
AaronPerrigo
B47853
11101Highway178 Bakersfield,CA93306
Monitoring System Certification
D.Results of Testing/Servicing
Software Version Installed:
Complete the following checklist:
Yes No*Isthe 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 oftank capacity does the alarm trigger? %
Yes*NoWas 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*NoWas 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:
Page 2 of 3
14.00
90
No sensors on site.
Monitoring System Certification
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 the 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 the Section H, below, describe how and when these deficiencies were or will be corrected.
H.Comments:
Page 3 of 3
89 plld did not catch leak,
87 plld was replaced. Confirm compliance by retesting
Leak Detector Test Results Sheet
Customer Address: Work Order: Site Address:
Test Date:
Site Contact: Phone:
Technician: Phone: 800-339-9930 ICC No.:
Product Type LLD Type Model Serial No. Check
Valve
Holding
Pressure
Bleed
Off ML.
Leak
Rate
Tested:
Pass/Fail
3 gph @
10 psi
3 gph @
10 psi
3 gph @
10 psi
3 gph @
10 psi
3 gph @
10 psi
3 gph @
10 psi
3 gph @
10 psi
3 gph @
10 psi
Technician Name: Technician No.:
Signature: Date:
MuthanaCorp.dbaMesaMarinChevron
11101Highway178
Bakersfield,CA93306
38219
8485827-UT
Regular Electronic PLLD
AaronPerrigo
(661)366-4886MohammudMuthana
Bakersfield,CA93306
11101Highway178
MesaMarinChevron
1850 Pass
PLLDElectronicPlus Fail
PLLDElectronicPremium 1920 Pass
PLLDElectronicDiesel 1825 Pass
AaronPerrigo 8485827-UT
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 forsubmittal to the local regulatory agency.
1.FACILITY INFORMATION
Facility Name:Date of Testing:
Facility Address:
Facility Contact:Phone:
Date Local Agency Was Notified of Testing :
Name of Local Agency Inspector (if present during testing):
2.TESTING CONTRACTOR INFORMATION
Company Name:Confidence UST Services, Inc.
Technician Conducting Test:
Credentials1:CSLB Contractor ICC Service Tech. SWRCB Tank Tester Other (Specify)
License Number(s):CSLB#804904 ICC#
3.SPILL BUCKET TESTING INFORMATION
Test Method Used:Hydrostatic Vacuum Other
Test Equipment Used:Lake TestEquipment Resolution:0.0625”
Identify Spill Bucket (By Tank
Number, Stored Product, etc.)
1234
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:
Bucket Depth:
Wait time between applying
vacuum/water and start of test:
Test Start Time (TI):
Initial Reading (RI):
Test End Time (TF):
Final Reading (RF):
Test Duration (TF – TI):
Change in Reading (RF -RI):
Pass/Fail Threshold or
Criteria:
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)
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:_________
1 State laws and regulations do not currently require testing to be performed by a qualified contractor. However, local requirements
may be more stringent.
MesaMarinChevron
11101Highway178 Bakersfield,CA93306
MohammudMuthana(661)366-4886
12/29/2016
AaronPerrigo
8485827-UT
Regular
12.00"
15.00"
5min.
9:15 am
9"
10:15 am
9"
1hour
0.00"
0.0625"
Plus
12.00"
14.75"
5min.
9:15 am
9.5"
10:15 am
9.5"
1hour
0.00"
0.0625"0.0625"
Super
12.00"
14.00"
5min.
9:15 am
9.5"
10:15 am
9.5"
1hour
0.00"
Diesel
12.00"
14.00"
5min.
9:15 am
9"
10:15 am
9"
1 hour
0.00"
0.0625"