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HomeMy WebLinkAboutFMC 2017 2/21/07 1 Appendix VI (Copies of Monitoring System Certification form and UST Monitoring Plot Plan available at http://www.waterboards.ca.gov.) 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: _____Beale Monterey ____ ________________________________________ Bldg. No.:___________________ Site Address: __900 Monterey St. ____ _____________________ City: _Bakersfield ____________ Zip: ____________________ Facility Contact Person: ___________________________________________ Contact Phone No.: (_______)__________________________ Make/Model of Monitoring System: Veeder-Root TLS-350________________________ Date of Testing/Servicing: _6_/ 29_/ 2017______ B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced: Tank ID: _ 87 UL__ _____________________________ X In-Tank Gauging Probe. Model: __Mag.______________ X Annular Space or Vault Sensor. Model: 794390-409 __ __ _ X Piping Sump / Trench Sensor(s). Model: 794380-208 __ __ _ X Fill Sump Sensor(s). Model: 794380-208 __ __ _ Mechanical Line Leak Detector. Model: ____________________ X Electronic Line Leak Detector. Model: Red Jacket CPT __ X Tank Overfill / High-Level Sensor. Model: __Mag.______________ Other (specify equipment type and model in Section E on Page 2). Tank ID: _ 91 UL _ _____________________________ X In-Tank Gauging Probe. Model: __Mag.______________ X Annular Space or Vault Sensor. Model: 794390-409 __ __ _ X Piping Sump / Trench Sensor(s). Model: 794380-208 __ __ _ X Fill Sump Sensor(s). Model: 794380-208 __ __ _ X Mechanical Line Leak Detector. Model: _FX1DV __ Electronic Line Leak Detector. Model: ____________________ X Tank Overfill / High-Level Sensor. Model: __Mag.______________ Other (specify equipment type and model in Section E on Page 2). Tank ID: _ 87 UL_ _____________________________ X In-Tank Gauging Probe. Model: __Mag.______________ X Annular Space or Vault Sensor. Model: 794390-409 __ __ _ X Piping Sump / Trench Sensor(s). Model: 794380-208 __ __ _ X Fill Sump Sensor(s). Model: 794380-208 __ __ _ Mechanical Line Leak Detector. Model: ____________________ Electronic Line Leak Detector. Model: ____________________ X Tank Overfill / High-Level Sensor. Model: __Mag.______________ Other (specify equipment type and model in Section E on Page 2). Tank ID: _ __ ____________________________ In-Tank Gauging Probe. Model: ____________________ Annular Space or Vault Sensor. Model: ____________________ Piping Sump / Trench Sensor(s). Model: ____________________ Fill Sump Sensor(s). Model: ____________________ Mechanical Line Leak Detector. Model: ____________________ Electronic Line Leak Detector. Model: ____________________ Tank Overfill / High-Level Sensor. Model: ____________________ Other (specify equipment type and model in Section E on Page 2). Dispenser ID: _1-2 __________________________________ X Dispenser Containment Sensor(s). Model: 794380-208 __ __ _ X Shear Valve(s). Dispenser Containment Float(s) and Chain(s). Dispenser ID: _7-8 __________________________________ X Dispenser Containment Sensor(s). Model: 794380-208 __ __ _ X Shear Valve(s). Dispenser Containment Float(s) and Chain(s). Dispenser ID: _3-4 __________________________________ X Dispenser Containment Sensor(s). Model: 794380-208 __ __ _ X Shear Valve(s). Dispenser Containment Float(s) and Chain(s). Dispenser ID: _9-10 _________________________________ X Dispenser Containment Sensor(s). Model: 794380-208 __ __ _ X Shear Valve(s). Dispenser Containment Float(s) and Chain(s). Dispenser ID: _5-6 __________________________________ X Dispenser Containment Sensor(s). Model: 794380-208 __ __ _ X Shear Valve(s). Dispenser ID: _11-12 ________________________________ X Dispenser Containment Sensor(s). Model: 794380-208 __ __ _ X Shear Valve(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): X System set-up X Alarm history report Technician Name (print): _Brandon W. Hinsley___________________ Signature: __________________________________________________ Certification No.: _B46140 _____________________________ License. No.: _8376986______________________________ Testing Company Name: _Advanced Compliance_______________________ Phone No.:(661) 706-4321______________________ Testing Company Address: _3704 Littlefalls Ct. Bakersfield, Ca. 93312______________________ Date of Testing/Servicing: _6_/_29_/_2017________ Monitoring System Certification Page 1 of 4 12/07 2/21/07 2 D. Results of Testing/Servicing Software Version Installed: _331.01______________________________ Complete the following checklist: X Yes No* Is the audible alarm operational? X Yes No* Is the visual alarm operational? X Yes No* Were all sensors visually inspected, functionally tested, and confirmed operational? X 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* X N/A If alarms are relayed to a remote monitoring station, is all communications equipment (e.g. modem) operational? X 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) X Sump/Trench Sensors; X Dispenser Containment Sensors. Did you confirm positive shut-down due to leaks and sensor failure/disconnection? X Yes No* X 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* X 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* X No Was liquid found inside any secondary containment systems designed as dry systems? (Check all that apply) yes, describe causes in Section E, below. X Yes No* Was monitoring system set-up reviewed to ensure proper settings? Attach set up reports, if applicable X 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: ___________________________________________________________________________________________ __________________________________________________________________________________________________________ __________________________________________________________________________________________________________ __________________________________________________________________________________________________________ __________________________________________________________________________________________________________ _________________________________________________________________________________________________________ __________________________________________________________________________________________________________ __________________________________________________________________________________________________________ __________________________________________________________________________________________________________ __________________________________________________________________________________________________________ __________________________________________________________________________________________________________ _________________________________________________________________________________________________________ __________________________________________________________________________________________________________ __________________________________________________________________________________________________________ __________________________________________________________________________________________________________ __________________________________________________________________________________________________________ __________________________________________________________________________________________________________ __________________________________________________________________________________________________________ Monitoring System Certification Page 2 of 4 12/07 2/21/07 3 F. In-Tank Gauging / SIR Equipment: X 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: X 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: X Yes X No* Were all LLDs confirmed operational and accurate within regulatory requirements? X Yes No* Was the testing apparatus properly calibrated? X Yes No* N/A For mechanical LLDs, does the LLD restrict product flow if it detects a leak? Yes No* X N/A For electronic LLDs, does the turbine automatically shut off if the LLD detects a leak? Yes No* X N/A For electronic LLDs, does the turbine automatically shut off if any portion of the monitoring system is disabled or disconnected? Yes No* X 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* X N/A For electronic LLDs, have all accessible wiring connections been visually inspected? 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: 87 Line Leak Detector Failed. _________________________________________________________________________________________ __________________________________________________________________________________________________________ __________________________________________________________________________________________________________ __________________________________________________________________________________________________________ __________________________________________________________________________________________________________ __________________________________________________________________________________________________________ __________________________________________________________________________________________________________ __________________________________________________________________________________________________________ __________________________________________________________________________________________________________ __________________________________________________________________________________________________________ __________________________________________________________________________________________________________ Monitoring System Certification Page 3 of 4 12/07 Monitoring System Certification UST Monitoring Site Plan Site Address: ________________________________________________________________________________________________ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 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Date map was drawn: ____/____/____. Instructions If you already have a diagram that shows all required information, you may include it, rather than this page, with your Monitoring System Certification. On your site plan, show the general layout of tanks and piping. Clearly identify locations of the following equipment, if installed: monitoring system control panels; sensors monitoring tank annular spaces, sumps, dispenser pans, spill containers, or other secondary containment areas; mechanical or electronic line leak detectors; and in-tank liquid level probes (if used for leak detection). In the space provided, note the date this Site Plan was prepared. Page _____ of _____05/00 Advanced Compliance 3704 Littlefalls Ct. Bakersfield, Ca. 93308 661-706-4321 Fax# 661-589-9329 VAPORLESS MANUFACTURING, INC. LDT-890 Leak Detector Test Record Contractor: Advanced Compliance Customer: Beale Monterey Date: 6/29/2017 Location: 900 Monterey St. Bakersfield,Ca. Product: 87 UL Technician: Brandon W. Hinsley Submersible Pump Identification Manufacturer: Redjacket Model No.: Serial No.: Notes: Leak Detector Identification Manufacturer: Redjacket Description: LLD Diaphragm-type: Piston-type: Tamper-proof seal installed: Other Style Leak Detector: Notes: Leak Detector in Submersible Pump Test at Dispenser Operating Pump Pressure (psi): 41 (para. 15) Gallons per hour rate: 3.0 (para. 22) Line pressure with pump shut off (psi): 41 (para. 23) Bleed-back Test with pump off (ml): N/A (para. 26) Step-through time to full flow (secs): 0 (para. 30) Leak detector stays in leak search position (Yes/No): N/A (para. 42) Leak Detector Test Pass / Fail Notes: Fail *Complete thermal expansion test before failing leak detector Advanced Compliance 3704 Littlefalls Ct. Bakersfield, Ca. 93308 661-706-4321 Fax# 661-589-9329 VAPORLESS MANUFACTURING, INC. LDT-890 Leak Detector Test Record Contractor: Advanced Compliance Customer: Beale Monterey Date: 6/29/2017 Location: 900 Monterey St. Bakersfield,Ca. Product: 91 UL Technician: Brandon W. Hinsley Submersible Pump Identification Manufacturer: Redjacket Model No.: Serial No.: Notes: Leak Detector Identification Manufacturer: Redjacket Description: LLD Diaphragm-type: Piston-type: Tamper-proof seal installed: Other Style Leak Detector: Notes: Leak Detector in Submersible Pump Test at Dispenser Operating Pump Pressure (psi): 41 (para. 15) Gallons per hour rate: 3.0 (para. 22) Line pressure with pump shut off (psi): 23 (para. 23) Bleed-back Test with pump off (ml): 95 (para. 26) Step-through time to full flow (secs): 3 (para. 30) Leak detector stays in leak search position (Yes/No): N/A (para. 42) Leak Detector Test Pass / Fail Notes: Pass *Complete thermal expansion test before failing leak detector 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: Beale Monterey Date of Testing: 6/29/2017 Facility Address: 900Monterey St. Bakersfield, Ca. 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: Advanced Compliance Technician Conducting Test: Brandon W. Hinsley Credentials1:  CSLB Contractor X ICC Service Tech.  SWRCB Tank Tester  Other (Specify) __________________ License Number(s): 8376986 3. SPILL BUCKET TESTING INFORMATION Test Method Used: X Hydrostatic  Vacuum  Other (Specify)____________________________ Test Equipment Used: Visual Equipment Resolution: Identify Spill Bucket (By Tank Number, Stored Product, etc.) 1 87 UL Fill 2 87 UL Fill 3 91 UL Fill 4 Bucket Installation Type:  Direct Bury X Contained in Sump  Direct Bury X Contained in Sump  Direct Bury X Contained in Sump  Direct Bury  Contained in Sump Bucket Diameter: 11” 11” 11” Bucket Depth: 11” 11” 11” Wait time between applying vacuum/water and start of test: 10 min. 10 Min. 10 Min. Test Start Time (TI): 08:45 08:45 08:45 Initial Reading (RI): 9.25” 9.50” 9.50” Test End Time (TF): 09:45 09:45 09:45 Final Reading (RF): 9.25” 9.50” 9.50” Test Duration (TF – TI): 1 Hr. 1 Hr. 1 Hr. Change in Reading (RF - RI): 0.0” 0.0” 0.0” Pass/Fail Threshold or Criteria: 0.25” 0.25” 0.25” Test Result: X Pass  Fail X Pass  Fail X 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: 6/29/2017 1 State laws and regulations do not currently require testing to be performed by a qualified contractor. However, local requirements may be more stringent.