Loading...
HomeMy WebLinkAbout6501 UNION (3)4 q, MONITORING SYSTEM CERTIFICATION For Use By All Jurisdictions Within the State ofCalifornia Authority Cited: Chapter 6. ? Ilealth and Safety Code; Chapter 16, Division 3, Title 23, California Code ofRegulations This form must be used to document testing and servicing of monitoring equipment. karate certification or report must be preAared 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 oftest date. A. General Information Facility Name: VG MINI MART Bldg. No.: Site Address: 6501 S. UNION City: BAKERSFIELD Zip: 93307 Facility Contact Person: ROGER Contact Phone No.: ( Make/Model ofMonitoring System: TLS -350 Date of Testing/Servicing: 6/27/2011 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced: Tank ID: UNL87 Tank ID: PREM91 SPLIT DIESEL In -Tank Gauging Probe. Model: MAGI In -Tank Gauging Probe. Model: MAGI Annular Space or Vault Sensor. Model: 420 Annular Space orVault Sensor. Model: 420 Piping Sump / Trench Sensor(s). Model: 208 Piping Sump / Trench Sensor(s). Model: 208 Fill Sump Sensor(s). Model: Fill Sump Sensor(s). Model: Mechanical Line Leak Detector. Model: FX1V Mechanical Line Leak Detector. Model: FX1 V Electronic Line Leak Detector. Model: Electronic Line Leak Detector. Model: Tank Overfill / High -Level Sensor. Model: FLAPPER Tank Overfill / High -Level Sensor. Model: FLAPPER Other (specify equipment type and model in Section E on Page 2). Other (specify equipment type and model in Section Eon Page 2). Tank 1D: DIESEL SPLIT PREM91 Tank ID: In -Tank Gauging Probe. Model: MAGI In -Tank Gauging Probe. Model: Annular Space orVault Sensor. Model: 420 Annular Space or Vault Sensor. Model: Piping Sunip / Trench Sensor(s). Model: 208 Piping Sump / Trench Sensor(s). Model: Fill Sump Sensor(s). Model: Fill Sump Sensor(s). Model: Mechanical Line Leak Detector. Model: LD -2000 Mechanical Line Leak Detector. Model: Electronic Line Leak Detector. Model: Electronic Line Leak Detector. Model: Tank Overfill / High -Level Sensor. Model: FLAPPER Tank Overfill / High -Level Sensor. Model. Other (specify equipment type and model in Section E on Page 2). Other (specify equipmenttype and model in Section E on Page 2). Dispenser ID: 1 -2 Dispenser ID: 3-4 Dispenser Containment Sensor(s). Mode): 351 DispenserContainment Sensor(s). Model: 351 Shear Valve(s). Shear Valve(s). Dispenser Containment Float(s) and Chain(s). DispenserContainment Float(s) and Chain(s). Dispenser ID: 5-6 Dispenser ID: Dispenser Containment Sensor(s). Model: 351 Dispenser Containment Sensor(s). Model: Shear Valve(s). ShearValve(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). ShearValve(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 ofthe report; (check all drat apply): ® System set -up ® Alarm history report Techniciap Name (print): RICHARD MASON Signature: 4_ - Certification No.: 83688015297857 -UT License. No.: C / D40 809850 Testing Company Name: RICH ENVIRONMENTAL Phone No.: (661) 392 -8687 Testing Company Address: 6643 BROOKS CT. BAKERSFIELD, CA 93308_ Date ofTesting/Servicing: 6/27/2011 Page 1 of 57 UN-036 -1/4 www.unidoes.org Rev. 01/17/08 Monitoring System Certification D. Results of Testing/Servicing Software Version Installed: 17.02 Complete the following checklist: 4zto f Yes No* Is the audible alarm operational? Yes p 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* If alarms are relayed to a remote monitoring station, is all communications equipment (e.g., modem) N/A operational? Yes No* For pressurized piping systems, does the turbine automatically shut down if the piping secondary containment N/A monitoring system detects a leak, fails to operate, or is electrically disconnected? Ifyes: 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* For tank systems that utilize the monitoring system as the primary tank oveMII warning device (i.e., no N/A mechanical overfill prevention valve is installed), is the overfill warning alarm visible and audible at the tank fill points) 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: Page 2 of 6— UN- 036 - 2/4 www.unidomorg Rev. 01/17/08 Monitoring. System Certification F. In-Tank Gauging I SIR Equipment: 47-1v1 q 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 ofsystem product level readings tested? Yes No* Was accuracy ofsystem water level readings tested? Yes No* Were all probes reinstalled properly? Yes No* I 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): ramnlrtr thr fnllnwina rhrrkliat- Check this box if LlDs are norinstalled. Yes No* For equipment start -up or annual equipment certification, was a leak simulated to verify LLD performance? N/A Check all that apply) Simulated leak rate: ® 3 g.p.h.; [10.1 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* For mechanical LLDs, does the LLD restrict product flow if it detects a leak? N/A Yes No* For electronic LLDs, does the turbine automatically shut off ifthe LLD detects a leak? N/A Yes No* For electronic LLDs, does the turbine automatically shut off if any portion of the monitoring system is disabled N/A or disconnected? Yes No* For electronic LLDs, does the turbine automatically shut off if any portion of the monitoring system malfunctions N/A or fails a test? Yes No* For electronic LLDs, have all accessible wiring connections been visually inspected? N/A 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: UN -036 — 3/4 Page 3 of www.unidoes.org Rev. 01/17/08 Monitoring System Certification Form: Addendum for Vacuum/Pressure Interstitial Sensors I. Results of Vacuum/Pressure Monitoring Equipment Testing q7_614 /11111 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: Model: System Type: Pressure; Vacuum Sensor ID Component(s) Monitored by this Sensor: 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 Component(s) Monitored by this Sensor: 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 Component(s) Monitored by this Sensor: 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 Component(s) Monitored by this Sensor: 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 Component(s) Monitored by this Sensor: 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;' Gauge; Visual Inspection; Other (Describe in Sec. J, below) Was vacuum/pressure restored to operating levels in all Interstitial spaces? Yes No (Ifno, describe in Sec. J, below) J. Comments: tJ l F's- Page 4 of _T__ 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. UN -036A - 1/1 www.uniducs.org Rev. 01126/06 Monitoring System Certification UST Monitoring Site Plan Site Address: N r —O 5. r.t= moo . - - -: ----= _= -_ - - -- -yam 1 - - `r J • _ - _ . . _ . _ - _ - - _ _ - _ • - - - - - - - - - - - - - - - • - - ----------------- r _ _ . - 3 - - - - - - - - - - - - r • _ _ _ _ _ _ _ _ _ _ _ _ _ r r . _ . _ • • . _ .. r - . - - - - - - - - - - - - - r r . • ° - - - - - - - - - - - _ _ . - - b . _ . . . . . r . r o - - - - - < • - - - - - - - - - - . r - - r - - _ Date reap was drawn, jai 02 Ina'- vetions Ifyou already have a diagram that shows all required information, you may include it, rather than this page, with your Ivionitoring System Cr tification. On your site plan, show the general layout oftanks and piping. Clearly identifylocationsofthefollowingequipment, if installed: monitoring system control pastels; sensors monitoring tank annular spaces, sumps, dispenser pans, spill containers, or other sccundary containment areas; mechasrfcal or electronic line leakdetectors; 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 05100 RICH ENVIRONMENTAL 5643 BROOKS CT. BAKERSFIELD, CA. 93308 OFFICE (661)392 -8687 FAX (661)392 -0621 PRODUCT LINE LEAK DETECTOR TEST WORK SHEET W /0 #: FACILITY NAME: VG MINI MART FACILITY ADDRESS: 6501 S. UNION BAKERSFIELD, CA PRODUCT LINE TYPE: PRESSURE IZlol 4 /--- PRODUCT LEAK DETECTOR TYPE TEST TRIP PASS BELOW P.S.I. OR SERIAL NUMBER 3 G.P.H. FAIL UNL87 L/D TYPE: MECHANICAL PASS YES SERIAL # RED JACKET PREM91 L/D TYPE: MECHANICAL PASS YES SERIAL # RED JACKET DIESEL L/D TYPE: MECHANICAL PASS YES SERIAL # LD -2000 IM TYPE YES PASS SERIAL # NO FAIL I CERTIFY THE ABOVE TESTS WERE CONDUCTED ON THIS DATE ACCORDING TO RED JACKET PUMPS FIELD TEST APPARATUS TESTING PROCEDURE AND LIMITATIONS. THE MECHANICAL LEAK DETECTOR TEST PASS / FAIL IS DETERMINED BY USING A LOW FLOW THRESHOLD TRIP RATE OF 3 GALLONS PER HOUR OR LESS AT 10 P.S.I. I ACKNOWLEDGE THAT ALL DATA COLLECTED IS TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE. TECHNICIAN: RICHARD MASON SIGNATURE: Ea. DATE: 6/27/11 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 (tfapplicable), should be provided to thefacility owner /operatorfor submittal to the local regulatory agency. 1. FACILITY INFORMATION Facility Name: VG MINTI MART I Date of Testing: 6/27/11 Facility Address: 6501 S. UNION BAKERFIELD, CA 93307 Facility Contact: ROGER Phone: Date Local Agency Was Notified ofTesting: Name ofLocal Agency Inspector (r(present duringtesting): 6/1/11 ERNIE MEDINA 2. TESTING CONTRACTOR INFORMATION CompanyjName: RICH ENVIRONMENTAL Technician Conducting Test: RICHARD MASON Credentials: CSLB Contractor X iCC Service Tech. SWRCB Tank Tester Other (Spec) License Number(s): 5297857 -UT 3. SPILL BUCKET TESTING INFORMATION Test Method Used: X Hydrostatic Vacuum Other Test Equipment Used: VISUAL Equipment Resolution: 0.00 Identify Spill Bucket (By Tank Number, Stored Product, etc. t UNL-87 MEEMEMENNEEMM Z PREW1 3 DIESEL 4 Bucket Installation Type: X Direct Bury Contained in Sump X Direct Bury Contained in Sump X Direct Bury Contained in Sump Direct Bury Contained in Sump Bucket Diameter: 12" 12" 12" Bucket Depth: 16" 16" 16" Wait time between applying vacuum /water and start oftest: 30 MIN 30 MIN 30 MIN Test StarGTime (Tj): I :OOPM 1:OOPM . I:OOPM Initial Reading (RO: 10" 10" 10" Test End Time (TF): 2:OOPM 2:OOPM 2:OOPM Final Reading (RF): 10" 10" 10" Test Duration (TF — T,): 1 -HOUR 1 -HOUR 1 -HOUR Change in Reading (RF - Rj): 0 0 0 Pass/Fail Threshold or Criteria: 0.00 0.00 0.00 r , a; HIM 141 V . t Comments — (include information on repairs made prior to testing; and recommendedfollow -upforfailed tests) CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING hereby certify that all the information contained in this report is true, accurate, and infull compllance with legal requirements. Technician's Signature: ` Date: 6/27/11 State laws and regulations do not currently require testing to be performed by a qualified contractor. However, local requirements may be more stringent. 4.w 4 / IN -TANK SETUP T I:DIESEL PRODUCT CODE 1 T 2:PREMIUM THERMAL COEFF :.000045 SYSTEM SETUPPRODUCTCODE2TANKDIAMETER. 96.00 i:2THERMALCOEFF :.000070TANKDJAI•IETER TANK PROFILE 20 FULL VOL PTS 5013 JUN 7. 1 FI° 2 `O1 TANK PROFILE : 96.00 20 PTS 91.2,INCH VOL 4928 FULL VOL : 7018 66.4 INCH VOL 4763 91,2 INCH VOL : 86.4 INCH 6899 81.6 INCH VOL : 76.8 INCH VOL 4552 4315 SYSTEM UNITSVOL : 81.6 INCH VOL : 6666 6376 72.0 INCH VOL 67.2 INCH VOL 4047 3767 U.S. SYSTEM LANGUAGE76.8 INCH VOL : 72.0 INCH VOL 6043 5666 62.4 INCH VOL 3464 ENGLISH 67.2 INCH VOL 5273 57.6 INCH VOL 3093 SYSTEM DATE /TIME FORMAT 62.4 INCH VOL 4249 52.8 INCH VOL 2847 MON DD YYYY HH:MM:SS xM 57,6 INCH VOL 52.3 INCH 4422 48.0 INCH VOL : 43.2 INCH VOL 2523 2208 V.G. MINI MARKETVOL 48.0 INCH VOL : 3985 3532 38.4 INCH VOL 1887 6501 S. UNION BAKERSFIELD CA"9330743.2 INCH VOL : 38,4 INCH 3091 33.6 INCH VOL : 28.8 INCH VOL : 1581 1285 661- 398 -6152VOL : 33.6 INCH VOL : 2642 2214 24.0 INCH VOL : 19.2 INCH VOL : 994 730 SHIFT TIME 1 5:00'AM28.8 INCH VOL : 24,0 INCH VOL 1799 14.4 INCH VOL 482 SHIFT TIME 2 DISABLED 19,2 INCH VOL : 1392 1022 9.6 INCH VOL : 272 SHIFT TIME 3 DISABLED 14.4 INCH VOL b75 4.8 INCH VOL 103 SHIFT TIME 4 DISABLED 9.6 INCH VOL 38I TANK PERIODIC WARNINGS4,8 INCH VOL 145 FLOAT SIZE: 4.0 IN. 9496 DISABLED TANK ANNUAL WARNINGS FLOAT SIZE: 4.0 Ill. 8496 WATER WARNING HIGH WATER LIMIT: 2.0 3.0 DISABLED LINE PERIODIC.' WARNINGS. WATER WARNING HIGH WATER LIMIT: 0 MAX OR LABEL VOL: 5010 DISABLED LINE ANNUAL WARNINGS 3.0 OVERFILL LIMIT 90: DISABLED MAX-. OR LABEL VOL: OVERFILL LIMIT 7014 HIGH PRODUCT 4509 95% PRINT TC VOLUMES 90% 4759 ENABLED HIGH PRODUCT 6,12 95o DELIVERY LIMIT 14i TEMP COMPENSATION DELIVERY LIMIT 6663 751 VALUE (DEG F ): 60.0 14 % LOW PRODUCT 500 STICK HEIGHT OFFSET 1052 LEAK ALARM LIMIT: 99 DISABLED LOW PRODUCT 599 SUDDEN LOSS LIMIT: 50 DAYLIGHT SAVING TIME LEAK ALARPI LIMIT: TANK TILT 0.00 STARTEDATESUDDENLOSSLIMIT: TANK TILT 50 MANIFOLDED TANKS APR WEEK 1 SUN 1,00 T #: NONE START TIME MANIFOLDED TANKS 2:00 AM END DATET #: NONE LEAK MIN PERIODIC: 9% OCT WEEK 6 SU14 JFO1 END TIME LEAK hIIN PERIODIC: 2:00 AM 70l1 LEAK MIN ANNUAL 9 501 LEAK MIN ANNUAL SYSTEM SECURITY 9 CODE : 000000 701 PERIODIC TEST TYPE STANDARD PERIODIC TEST TYPE STANDARD ANNUAL TEST FAIL ALARM DISABLED ANNUAL TEST FAIL ALARM DISABLED PEk1ODIC TEST FAIL ALARM DISABLED PERIODIC TEST FAIL ALARM DISABLED GROSS TEST FAIL ALARM DISABLED GROSS TEST FAIL SOFTWARE REVISION LEVEL ALARM DISABLED ANN TEST AVERAGING: OFF VERSION 17.02 PER TEST AVERAGING: OFF GSOFTWARE# 346017 -100 -. ANN TEST AVERAGING: OFF CREATED - 99.01.12.18.20 PER TEST AVERAGING,: OFF TANK TEST NOTIFY: OFF NO'SOFTWARE MODULE TANK TEST NOTIFY: OFF TNK TST SIPHON BREAK :OFF. SYSTEM FEATURES: PERIODIC IN -TANI: TESTS, TNK TST SIPHON BREAK OFF DELIVERY DELAY : 3 MIN ANNUAL IN -TANK TESTS DEL. I1IFA',! - - , . Hj,pR H1STOR`' RFpLS S O ORT T 3:UNLEADEDSFNULAIs ,pFSEL R Rl _ ALARM PRODUCT CODE JUNR 0 qCE NtyUR HISTORY REPORT THERMAL COEFF :.00007( TANK DIAMETER, .96. Di FUFL ' X011 % L 'I:87SENSOR ALARM TANK PROFILE 20 PTI JUN 2 LHRM ANNULAR FULL VOL, :. 12131 201 SENSOR OUT 91.2 IIV<,H VOL 1193': 86.4 INCH VOL 1151tJFvI1 2:2g JUN 27. 2011 2: 81.6 INCH VOL 1103( UN 14 S01GLR p/y JUN 2 3q F7h 72.0 INCH VOL : 1045, 980` 1 , 7' 2011 2 .26 phi . 67,2 INCH VOL 910( SENSOR x 62.4 INCH VOL 839; OUT 57.6 INCH VOL 763` JUN !4. 20100 !1 52.8 INCH VOL 688: Am COMMUNICATIONS SETUP 48.0 INCH VOL 611: 43.2 INCH VOL 533: 38.4 INCH VOL 457! 33.6 INCH VOL '382! PORT SETT 1434 : 28.8 INCH VOL : 3101 24.0 INCH VOL : 240': NONE FOUND 19.2 INCH VOL 176 LEAK TEST METHOD 14.4 INCH VOL : 117 9.6 INCH VOL 65`. CODE : 000000 SECURITY TEST ANNUALLY: ALL TANK 4.6 1NCH VOL 24• CO JAN WEEK 1 MON START TIME : 2:00 AM TEST RATE :0.20 GAL /HR FLOAT SIZE: 4:0 IN, 8491 DURATION 2 HOURS WATER WARNING• 2.1 RS -232 END OF MESSAGE HIGH WATER LIMIT: 3.1 DISABLED LEAK TEST REPORT FORMAT MAX OR LABEL VOL: 1213' ENHANCED OVERFILL LIMIT 90` 1092! HIGH PRODUCT 951 1 l 53: DELIVERY LIMIT 9: 120: OUTPUT RELAY SETUP — — LOW PRODUCT 1001 LEAK ALARM LIMIT: 9' SUDDEN LOSS LIMIT: 51 R 1:87 TANK TILT 0.01 TYPE: MANIFOLDED TANKSSTANDARDLIQUIDSENSORSETUP NORMALLY CLOSED — — — — — — — — — — — — TO: NONE L 1:87 ANNULAR LIQUID SENSOR ALMS TRI —STATE (SINGLE FLOAT) LEAK MIN PERIODIC: 9: ALL:FUEL ALARM CATEGORY ANNULAR SPACE 120: ALL-SENSOR OUT ALARM LEAK h11IV ANNUAL 9` 120. R 2'92 L 2:92 — DIESEL ANNULARTYPE' TRI —STATE (SINGLE FLOAT) STANDARD 12NALLY CLOSED CATEGORY : ANNULAR SPACE PERIODIC TEST TYPE STANDARI LIQUID SENSOR ALMS ANNUAL TEST FAIL ALL:FUEL ALARM L 3:DIESEL STP ALARM DISABLEI r:LL:SENSOR OUT ALARM TRI —STATE (SINGLE FLOAT) CATEGORY : STP SUMP PERIODIC• TEST FAIL R 3-DIESEL ALARM DISABLE) TYPE' 4:92 STP GROSS TEST FAILSTANDARD NORMALLY CLOSED TRI —STATE (SINGLE FLOAT) ALARM DISABLE] CATEGORY : STP SUMP ANN TEST AVERAGING: OF] LIQUID SENSOR ALMS PER TEST AVERAGING: OF] L 2 :FUEL ALARM L 5:87 STP L 3:FUEL AL TRI —STATE (SING,LE FLOAT) TANK TEST NOTIFY: OF] L 3 :SENSOR OUT ALARIh CATEGORY : STP SUMP . TIVk:.TST SIPHON Bk &AK :OFI q7,wq / LARM HISTORY ~REPORT SENSOR ALARM - - - -- L 3:DIESEL STP STP SUMP SENSOR OUT ALARM JUN 27, 2011 2:34 PM FUEL .ALARM JUN 27, 2011 2:23 PM SENSOR OUT ALARM JUN 14, 2010 10:11 AM ALARM HISTORY REPORT SENSOR ALARM 4:92 STP STP SUMPSENSOROUT ALARM 34 PM JUN 27• 2011 2: FUEL ALARM 'J122 PM JUN 27• 2011 SENSOR OUT 010AjOM11 AM N HISTORY REPORT M - SENSOR ALARM -- STP SUMP P Sews O201ALA21.34 PM JUN 2 JUN L ALARM 2:24 PM EN t14 02p10 10-.11 Nwi4 MONITOR CERT. FAILURE REPORT SITE NAME: VG MINI MART DATE: 6/27/11 ADDRESS: 6501 S. UNION TECHNICIAN: RICHARD 1MASON CITY: BAKERSFIELD SIGNATURE: ° Y THE FOLLOWING COMPONENTS WERE REPLACED/REPAIIRED TO COMPLETE TESTING. REPAIRS: NONE LABOR: NONE PARTS INSTALLED: NONE NAME: TITLE: SIGNATURE: THE ABOVE NAMED PERSON TAKES FULL RESPONSIBILITY OF NOTIFYING THE APPROPRIATE PARTY TO HAVE CORRECTIVE ACTION TAKEN TO REPAIR THE ABOVE LISTED PROBLEMS AND NOTIFYING RICH ENVIRONMANTAL FOR ANY NEEDED RETESTING. THIS ALSO RELEASES RICH ENVIRONMENTAL OF ANY FINES OR PENALTIES OCCURING FROM NON - COMPLIANCE. A COPY OF THIS DOCUMENT HAS BEEN LEFT ON -SITE FOR YOUR CONVIENENCE.