HomeMy WebLinkAboutFMC 20112 -i
MONITORING SYSTEM CERTIFICATION
For Use By AllJurisdictions 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 ofthis form to the local agency regulating UST systems
within 30 days of this date.
A. General Information
Facility Name: Flower Street Mini Market
Site Address: 928 Flower Street
Facility Contact Person: Hussain Monsour
Make /Model of Monitoring System: Veeder -Root TLS 350
B. Inventory of Equipment Tested /CertifiedChecktheappropriatebo:a to in citespecific equipment Inspected /serviced:
City: Bakersfield
Bldg. No.:
Zip: 93305
Contact Phone No.: 661 - 328 -0732
Date of Testing/Servicing: 12/15/2011
Tank ID: 10000 gal. Regular Tank
x]
ID: 8000 gal. Super
In -Tank Gauging Probe. Model: 847390 -107X] In -Tank Gauging Probe. Model: 847390-107
x] Annular Space or Vault Probe. Model: 794390-420 X] Annular Space or Vault Sensor. Model: 794390.420
x] Piping Sump / Trench Sensor(s). Model :794389 -208 x] Piping Sump / Trench Sensor(s). Model: 794389 -208
X] Fill Sump Sensor(s) Model: 794389 -208 U Fill Sump Sensor(s). Model: 794389 -208
X] Mechanical Line Leak Detector. Model:FXIV X] Mechanical Line Leak Detector. Model: FX1V
Electronic Line Leak Detector. Model: Electronic Line Leak Detector. Model:
U Tank Overfill / High Level Sensor. Model: 847390-107 U Tank Overfill / High Leval Sensor. Model: 847390 -107
Other (specify equip. type and model in Sec. E on Pg. 2) Other (specify equip. type and model in Sec. E on Pg. 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 Sensors(s). Model: Fill Sump Sensor(s). Model:
Mechanical Line Leak Decector. 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 equip. type and model in Sec. E on Pg. 2) Other (specify equip. typs and model in Sec. E on Pg. 2)
Dispenser ID: 1 & 2 Dispenser ID: 3&4
7 Dispenser Containment Sensor(s). Model: 794389 - 208 Lx] Dispenser Containment Sensor(s). Model: 794389 -208
X] Shear Valve(s). X] Shear Valve(s).
Dispenser Containment Float(s) and Chain(s). Dispenser Containment Float(s) and Chain(s)
Dispenser ID: 5 & 6 Dispenser ID: 7&8
x] Dispenser Containment Sensor(s). Model: 794389 - 208 Lx] Dispenser Containment Sensor(s). Model: 794389 -208
x] Shear Valve(s). X] Shear Valve(s).
Dispenser Containment Float(s) and Chains(s). Dispenser Containment Float(s) and Chain(s).
Dispenser ID: 98,10 Dispenser ID: 11 8t 12
x] Dispenser Containment Sensor(s). Model: 794389 -208 x] Dispenser Containment Sensor(s). Model: 794389 -208
LX] Shear Valve(s). LJ 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 /services in accordance with the
manufacturers' guidlines. Attached to this Certification is information (e.g. manufacturers' checklist) necessary to verify that
this information is correct and a plot plan showing the layout of monitoring equipment. For equipment capable of generating
such reports, l have attached a copy of the report; (check all that apply) x Syste -up UAlarm phlatTieport
Technician Name (print): Bryan A Self Signature:
Certification No: 837601 License No: 804904
Testing Company Name: Confidence UST Services, Inc. Phone No: 800- 339 -9930
Site Address: 928 Flower Street Bakersfield, CA 93306 Date of Testing/Servicing: 12/1612011
D. Results of Testing /Servicing
Software Version Installed: 323.03
Complete the following checklist:
x] Yes No* Is the audible alarm operational?
x Yes No* Is the Visual alarm operational?
x I Yes I I No* Were all sensors visually inspected, functionally tested, and confirmed operational?
x Yes No* Were all sensors installed at the lowest point of secondary containment and positioned so that other
equipment will not interfere with their proper operation?
Yes No* If alarms are relayed to a remote monitoring station, is all communications equipment (e.g. modem) Hx N/A operational?
x Yes No* For pressurized piping systems, does the turbine automatically shut down if the piping secondary
N/A containment monitoring system detects a leak, fails to operate, or is electrically disconnected? If yes:
which sensors initate positive shut - down? [xj Sump /Trench Sensors [x] Dispenser Containment Sensors
Did you confirm positive shut -down due to leaks and sensor failure /disconnected? [x] Yes; No;
Fx] Yes No* For tank systems that utilize the monitoring system as the primary tank overfill warning device (i.e. no
N/A mechanical overfill prevention valve is installed), is the overfill warning alarm visual and audible at
the tank fill point(s) and operating properly? If so, at what percent of tank capasity does the alarm
trigger? L90 %
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.
rx] Yes* No Was liquid found inside any secondary containment systems designed as dry systems?
Product; U Water. If yes, describe causes in Section E, below.
x No* Was monitoring system set -up reviewed to ensure proper settings? Attach set -up reports, if applicable.
x yeS No* I Is all monitoring equipment operational per manufacturer's specifications?
In Section E below, discribe how and when these deficiencies were or will be corrected.
E. Comments' Replaced 794389 -208 Sensor in the Super STP sump. I also replaced the 794390 -420 annular sensor.
I pulled out appox. 3 gallons of water from the super STP sump.
F. In- Tank Guaging / SIR Equipment: [X] Check this box if tank guaging is used only for inventory control.
Check this box if tank guaging or SIR equipment is installed.
This section must be completed if in -tank guaging equipment is used to perform leak detection monitoring.
Complete the following checklist:
rx] Yes No* Has all input wiring been inspected for proper enter and termination,including testing for ground faults?
x Yes No* Were all tank guaging probes visually inspected for damage and residue buildup?
x Yes No* Was accuracy of system product level readings tested?
x Yes El No* Was accuracy of system water level readings tested?
x Yes No* Were all probes reinstalled properly?
U Yes No* I 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 LLD's are not installed.
Complete the following checklist:
Lx] Yes No* For equip. start-up or annual equipment certification, was a leak simulated to varify LLD performance?
Check all that apply) Simulated leak rate: Lx]3 g.p.h.: 0.1 g.p.h.; 00.2 g.p.h.;
Lx=l Yes No* Were all LLD's confirmed operational and accurate within regulatory requirments?
x Yes No Was the testing apparatus properly calibrated?
x] Yes No* For mac amca LLD's, does the LLD restrict product flow if it detects a leak?
N/A
Yes No* For electronic LLD's, does the turbine automatically shut off if the LLD detects a leak?
Lx] N/A
Yes No* For electronic LLD's, does the turbine automatically shut off if any portion of the monitoring system is
x] N/A disabled or disconnected?
Yes No* For electronic LLD's, does the turbine automatically shut off if any portion of the monitoring system
x] N/A malfunction or fails a test?
Yes No* For electronic LLD's, have all accessible wiring connections been visually inspected?
X] N/A
x Yes 0 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:
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DEC 15. 2011 10:22 o-ifl
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DEC,' 15, 2011 10:08 W1
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DEC 15, '2101 1 10: i9 AM
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DEC' 17. 2010 9 :3`3 Hl,l
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DEC 15. 2011 10:1,7 411
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DEC 15. 2011 10 2-2
SWRCB, January 2006
Spill Bucket Testing Report Form
Thisform is intendedfor use by contractors performing annual testing of UST spill containment structures. The completedform and
printouts from tests (ifapplicable), should be provided to thefacility owner /operatorfor submittal to the local regulatory agency.
1. FACILITY INFORMATION
Facility Name: Flower Street Mini Market Date of Testing: 12/15/2011
Facility Address: 928 Flower Street Bakersfield, CA 93305
Facility Contact: Hussain Monsour Phone: 661- 328 -0732
Date Local Agency Was Notified of Testing : 1 1\19\2011
Name of Local Agency Inspector (rfpresent during testing): Ernie Medina
2. TESTING CONTRACTOR INFORMATION
Company Name: Confidence UST Services, Inc.
Technician Conducting Test: Bryan A Self
Credentials: X CSLB Contractor X ICC Service Tech. X SWRCB Tank Tester Other (Specify)
License Number(s): CSLB #804904 ICC #8022804 -UT Tank Tester 1 1 -1756
3. SPILL BUCKET TESTING INFORMATION
Test Method Used: x Hydrostatic Vacuum Other
Test Equipment Used: Lake Test Equipment Resolution: 0.0625"
Identify Spill Bucket (By Tank
Number, Stored Product, etc.
1 Regular 2 Plus 3 4
Bucket Installation Type: x Direct Bury
Contained in Sump
x Direct Bury
Contained in Sump
Direct Bury
Contained in Sump
Direct Bury
Contained in Sum
Bucket Diameter: 12.00" 12.00"
Bucket Depth: 15.00" 9.50"
Wait time between applying
vacuum /water and start of test:
5 min. 5 min.
Test Start Time (Ti): 9:00am 9:00am
Initial Reading (Rj): 10.50" 9.00"
Test End Time (TF): 10:00am 10:00am
Final Reading (RF): 10.50" 9.00"
Test Duration (TI. — Ti): 5 min. 1 hour
Change in Reading (RF - Ri): 0.00" 0.00"
Pass /Fail Threshold or
Criteria: 0.0625" 0.0625"
Test Result: X Pass Fail X Pass Fail Pass Fail Pass Fall
Comments — (include information on repairs made prior to testing, and recommendedfollow -upforfailed tests)
CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING
I hereby certify that all the information contained in this report is true, accurate, and infull compliance with legal requirements.
Technician's Signature: _f -- kAl— 5?!q Date: 12/15/2011
State laws and regulations do not curtly require testing to be pergrmed by a qualified contractor. However, local requirements
may be more stringent. /
0
4,5 4,6,7 4 4,6,7
87 91
FLOWER ST MINI MART
928 FLOWER ST
BAKERSFIELD, CA 93305
SENSOR KEY
1) TLS 350
2) OVERFILL ALARM
3) ESO
4) VEEDEROOT 208 LIQUID SENSOR
5) VEEDEROOT 420 ANNULAR SENSOR
6) VEEDEROOT ATG PROBE
7) RED JECKET FX1 V LLD