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HomeMy WebLinkAboutFMC 2018 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: _____Sully’s Grand Island ____ ________________________________________ Bldg. No.:___________________ Site Address: __11400 Ming Ave____ _____________________ City: _Bakersfield ____________ Zip: ____________________ Facility Contact Person: ___________________________________________ Contact Phone No.: (_______)__________________________ Make/Model of Monitoring System: Veeder-Root TLS-350________________________ Date of Testing/Servicing: _2_/_22_/_2018________ 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: 001/420 __ __ _ X Piping Sump / Trench Sensor(s). Model: 794380-208/304 __ __ _ X Fill Sump Sensor(s). Model: 794380-208/304 _______ X Mechanical Line Leak Detector. Model: _FX-1V __ 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: _ 91 UL _ _____________________________ X In-Tank Gauging Probe. Model: __Mag.______________ X Annular Space or Vault Sensor. Model: 001/420 __ __ _ X Piping Sump / Trench Sensor(s). Model: 794380-208/304 __ __ _ X Fill Sump Sensor(s). Model: 794380-208/304 _______ X Mechanical Line Leak Detector. Model: _FX-1V __ 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: _ Diesel_ _____________________________ X In-Tank Gauging Probe. Model: __Mag.______________ X Annular Space or Vault Sensor. Model: 001/420 __ __ _ X Piping Sump / Trench Sensor(s). Model: 794380-208/304 __ __ _ X Fill Sump Sensor(s). Model: 794380-208/304 _______ X Mechanical Line Leak Detector. Model: _FX-1DV _ 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 /304 __ __ _ X Shear Valve(s). Dispenser Containment Float(s) and Chain(s). Dispenser ID: _7-8 __________________________________ X Dispenser Containment Sensor(s). Model: 794380-208 /304 __ __ _ X Shear Valve(s). Dispenser Containment Float(s) and Chain(s). Dispenser ID: _3-4 __________________________________ X Dispenser Containment Sensor(s). Model: 794380-208/304 __ __ _ X Shear Valve(s). Dispenser Containment Float(s) and Chain(s). Dispenser ID: _9-10 ______ ____________________________ X Dispenser Containment Sensor(s). Model: 794380-208/304 __ __ _ X Shear Valve(s). Dispenser Containment Float(s) and Chain(s). Dispenser ID: _5-6 __________________________________ X Dispenser Containment Sensor(s). Model: 794380-208/304 __ __ _ X Shear Valve(s). Dispenser ID: _11-12________ _ ________________________ X Dispenser Containment Sensor(s). Model: 794380-208/304 __ __ _ 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): _Bradley W. Hinsley___________________ Signature: __________________________________________________ Certification No.: _B46141 _____________________________ License. No.: _971259 C61/D40______________________________ Testing Company Name: _Advanced Compliance_______________________ Phone No.:(661) 706-4321______________________ Testing Company Address: _3704 Littlefalls Ct. Bakersfield, Ca. 93312______________________ Date of Testing/Servicing: _2_/_22_/_2018________ Monitoring System Certification Page 1 of 4 12/07 2/21/07 2 D. Results of Testing/Servicing Software Version Installed: _333.02______________________________ Complete the following checklist: X Yes No* Is the audible alarm operational? X Yes No* Is the visual alarm operational? Yes X 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 X 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? ___90___% 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: 304_sensor_in_dispenser_15/16_would_not_alarm.___________________________________________________________ __________________________________________________________________________________________________________ __________________________________________________________________________________________________________ __________________________________________________________________________________________________________ __________________________________________________________________________________________________________ _________________________________________________________________________________________________________ __________________________________________________________________________________________________________ __________________________________________________________________________________________________________ __________________________________________________________________________________________________________ __________________________________________________________________________________________________________ __________________________________________________________________________________________________________ _________________________________________________________________________________________________________ __________________________________________________________________________________________________________ __________________________________________________________________________________________________________ __________________________________________________________________________________________________________ __________________________________________________________________________________________________________ __________________________________________________________________________________________________________ __________________________________________________________________________________________________________ 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 X Yes 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: _______________________________________________________________________ __________________________________________________________________________________________________________ __________________________________________________________________________________________________________ __________________________________________________________________________________________________________ __________________________________________________________________________________________________________ __________________________________________________________________________________________________________ __________________________________________________________________________________________________________ __________________________________________________________________________________________________________ __________________________________________________________________________________________________________ __________________________________________________________________________________________________________ __________________________________________________________________________________________________________ Monitoring System Certification Page 3 of 4 12/07 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: Sully’s Grand Island Date: 2/22/2018 Location: 11400 Ming Ave. Bakersfield, Ca. Product: 87 UL Technician: Bradley W. Hinsley Submersible Pump Identification Manufacturer: Redjacket Model No.: Serial No.: Notes: Leak Detector Identification Manufacturer: Redjacket Description: FX-1V 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): 35 (para. 15) Gallons per hour rate: 3.0 (para. 22) Line pressure with pump shut off (psi): 18 (para. 23) Bleed-back Test with pump off (ml): 100 (para. 26) Step-through time to full flow (secs): 3 (para. 30) Leak detector stays in leak search position (Yes/No): Yes (para. 42) Leak Detector Test Pass / Fail Notes: Pass *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: Sully’s Grand Island Date: 2/22/2018 Location: 11400 Ming Ave. Bakersfield, Ca. Product: 91 UL Technician: Bradley W. Hinsley Submersible Pump Identification Manufacturer: Redjacket Model No.: Serial No.: Notes: Leak Detector Identification Manufacturer: Redjacket Description: FX-1V 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): 32 (para. 15) Gallons per hour rate: 3.0 (para. 22) Line pressure with pump shut off (psi): 15 (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): Yes (para. 42) Leak Detector Test Pass / Fail Notes: Pass *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: Sully’s Grand Island Date: 2/22/2018 Location: 11400 Ming Ave. Bakersfield, Ca. Product: Diesel Technician: Bradley W. Hinsley Submersible Pump Identification Manufacturer: Redjacket Model No.: Serial No.: Notes: Leak Detector Identification Manufacturer: Redjacket Description: FX-1DV 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): 38 (para. 15) Gallons per hour rate: 3.0 (para. 22) Line pressure with pump shut off (psi): 21 (para. 23) Bleed-back Test with pump off (ml): 115 (para. 26) Step-through time to full flow (secs): 3 (para. 30) Leak detector stays in leak search position (Yes/No): Yes (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: Sully’s Grand Island Date of Testing: 2/22/2018 Facility Address: 11400 Ming Ave. 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: Bradley W. Hinsley Credentials1: X CSLB Contractor  ICC Service Tech.  SWRCB Tank Tester  Other (Specify) __________________ License Number(s): 971259 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 91 UL Fill 3 Diesel 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): 08:30 08:30 08:30 Initial Reading (RI): 9.75” 9.50” 9.75” Test End Time (TF): 09:30 09:30 09:30 Final Reading (RF): 9.75” 9.50” 9.75” 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: 2/22/2018 1 State laws and regulations do not currently require testing to be performed by a qualified contractor. However, local requirements may be more stringent. Monitoring System Certification Form: Addendum for Vacuum/Pressure Interstitial Sensors I. Results of Vacuum/Pressure Monitoring Equipment Testing This page should be used to document testing and servicing of vacuum and pressure interstitial sensors. A copy of this form must be included with the Monitoring System Certification Form, which must be provided to the tank system owner/operator. The owner/operator must submit a copy of the Monitoring System Certification Form to the local agency regulating UST systems within 30 days of test date. Manufacturer: Veeder-Root Model: TLS-350 System Type: Pressure; Vacuum Sensor ID s1 Component(s) Monitored by this Sensor: Unleaded Product Sensor Functionality Test Result: Pass; Fail Interstitial Communication Test Result: Pass; Fail s2 Component(s) Monitored by this Sensor: Vapor Sensor Functionality Test Result: Pass; Fail Interstitial Communication Test Result: Pass; Fail s3 Component(s) Monitored by this Sensor: Unleaded Tank Annular Sensor Functionality Test Result: Pass; Fail Interstitial Communication Test Result: Pass; Fail s4 Component(s) Monitored by this Sensor: Unleaded Vent Sensor Functionality Test Result: Pass; Fail Interstitial Communication Test Result: Pass; Fail s5 Component(s) Monitored by this Sensor: Supreme Product Sensor Functionality Test Result: Pass; Fail Interstitial Communication Test Result: Pass; Fail s6 Component(s) Monitored by this Sensor: Supreme Vent Sensor Functionality Test Result: Pass; Fail Interstitial Communication Test Result: Pass; Fail s7 Component(s) Monitored by this Sensor: Supreme Tank Annular Sensor Functionality Test Result: Pass; Fail Interstitial Communication Test Result: Pass; Fail s9 Component(s) Monitored by this Sensor: Diesel Vent Sensor Functionality Test Result: Pass; Fail Interstitial Communication Test Result: Pass; Fail s10 Component(s) Monitored by this Sensor: Diesel Product Sensor Functionality Test Result: Pass; Fail Interstitial Communication Test Result: Pass; Fail Component(s) Monitored by this Sensor: Sensor Functionality Test Result: Pass; Fail Interstitial Communication Test Result: Pass; Fail How was interstitial communication verified? Leak Introduced at Far End of Interstitial Space;1 Gauge; Visual Inspection; Other (Describe in Sec. J, below) Was vacuum/pressure restored to operating levels in all interstitial spaces? Yes No (If no, describe in Sec. J, below) J. Comments: 11400 Ming Ave. Bakersfield, Ca. 2/22/2018. 1 If the sensor successfully detects a simulated vacuum/pressure leak introduced in the interstitial space at the furthest point from the sensor, vacuum/pressure has been demonstrated to be communicating throughout the interstice.