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HomeMy WebLinkAbout5201 WHITE LANE (4)A 55 MONITORING SYSTEM CERTIFICATION For Use By All Jurisdictions Within the State ofCalifornia Y Authority Cited. Chapter 6.7, Health 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. A separate certification or report must be prepared for each monitoring system control panel by the technician who performs the work. A copy ofthis 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: GOOD SAMARITAN Site Address: 6201 WHITE LANE Bldg. No.: City: BAKERSFIELD, CA Zip: - Facility Contact Person: Contact Phone No.: ( ) Make/Model of Monitoring System: TLS -350 Date of Testing/Servicing; 10 -21 -11 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected /serviced: Tank ID: DIESEL in -Tank Gauging Probe. Model: MAG -1 Annular Space or VaultSensor. Model: 420 Piping Sump / Trench Sensor(s). Model: 208 Fill Sump Sensor(s). Model: Mechanical Line Leak Detector. Model: Electronic Line Leak Detector. Model: Tank Overfill / High -Level Sensor. Model: FLAPPER 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). 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 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). Ifthe 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 o nerating such reports, I have also attached a copy of the report; (check all that apply): ® System set -up Alarm h report Technician Name (print): RICH PHILLIPS Signature: Certification No.: A29084/1035169 -UT License. No.: 61/ D40 809850 Testing Company Name: RICH ENVIRONMENTAL Phone No.: (661) 326 -8402 Testing Company Address: 5643 BROOKS COURT BAKERSFIELD,CA 93308 Date of Testing/Servicing: 10 -21 -11 Page 1 of 5 UN -036 —1/4 www.unidoes.org Rev. 01117/08 Monitoring System Certification I D. Results of Testing/Servicing Software Version Installed: 15.01 Complete the following checklist: Yes No* Is the 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* 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? 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* 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 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* 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. Ifyes, describe causes in Section E, below. Yes No* Was monitoring system set -up reviewed to ensure proper settings? Attach set up reports, ifapplicable Yes No* I 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: SUCTION SYSTEM TO GENERATOR NO P.O.S Page 2 of 5 UN -036 — 214 www.unidocs.org Rev. 01/17108 twonitoring System Certification F. In -Tank Gauging / SIR Equipment: qqtq r 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* 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): rmmnlete the fallnwino checklist: Check this box if LLDs are not installed. Yes D No* For equipment start -up or annual equipment certification, was a leak simulated to verify LLD performance? rO N/A Check all that apply) Simulated leak rate: 3 gp.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* 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 if the 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 ofthe 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 M, below, describe how and when these deficiencies were or will be corrected. H. Comments: SUCTION SYSTEM. NO LEAK DETECTORS UN -036 — 314 Page 3 of 5 www.unidocs.org Rev. 01/17/08 SOFTWARE REVISION LEVEL VERSION 15.01 SOFTWARE# 346015 -100 -0 CREATED - 97.10.23.08.56 S- MODULEO 330161 -001 -A SYSTEM FEATURES: PERIODIC IN -TANK, TESTS ANNUAL IN -TANK TESTS 0.20 GAL /HR PLLDPRECISIONTESTSPECIAL YSTEM SETUP T 21. 2011 9:29 AM YSTEM UNITS U.S. YSTEM LANGUAGE ENGLISH YSTEM DATE /TIME FORMAT N DD YYYY HH:NIM:SS xM EMORIAL CENTER 201 WHITE LANE IKERSFIELD CA 15- 398 -1800 IIFT TIME I DISABLED jIFT TIME 2 DISABLED lIFT TIME 3 DISABLED RIFT TIME 4 DISABLED INK PERIODIC WARNINGS ISABLED INK ANNUAL WARNINGS ISABLED ' NE PERIODIC WARNINGS ISABLED NE ANNUAL WARNINGS PSABLED RINT TC VOLUMES VABLEI> - MP COMPENSATION II.UE (DEG F ) : 60.0 LICK HEIGHT OFFSET SABLED PROTOCOL DATA FORMAT I GHT 3YLIGHT SAVING TIME TABLED WRT DATE R WEE SUN ART O0;'':, CD HATE 7T WEEK 6 SUN 9D TIME k0000 AM I I- DIRECT LOCAL PRINTOUT SABI,ED STEM SECURITY DE : 000000 t COMMUNICATIONS SETUP PORT SETTINGS: COMM BOARD 2 (RS-232) BAUD RATE 1200 PARITY ODD STOP BIT 1 STOP DATA LENGTH: 7 DATA AUTO TRANSMIT SETTINGS: AUTO LEAK ALARM LIMIT DISABLED - AUTO HIGH WATER LIMIT DISABLED AUTO OVERFILL LIMIT DISABLED AUTO LOW PRODUCT DISABLED AUTO THEFT LIMIT DISABLED AUTO DELIVERY START DISABLED AUTO DELIVERY END DISABLED AUTO EXTERNAL INPUT ON DISABLED AUTO EXTERNAL INPUT OFF DISABLED AUTO SENSOR FUEL ALARM DISABLED AUTO SENSOR WATER ALARM DISABLED AUTO SENSOR OUT ALARM DISABLED RS -232 SECURITY CODE : 000000 RS -232 END OF MESSAGE DISABLED IN -TANK SETUP T I:DIESEL 2 PRODUCT CODE 1 THERMAL COEFF :.000450 TANK, DIAMETER 63.00 TANK PROFILE I PT FULL VOL 999 FLOAT SIZE: 4.0 IN. 8496 WATER WARNING 2.0 HIGH WATER LIMIT: 3.0 MAX OR LABEL VOL: 999 OVERFILL LIMIT 901/0 899 HIGH PRODUCT 95% 949 DELIVERY LIMIT 10i 99 LOW PRODUCT 80 LEAK ALARM LIMIT: 99 SUDDEN LOSS LIMIT: 50 TANK TILT 1.00 MANIFOLDED TANKS TO: NONE LEAK MIN PERIODIC: 0% 0 LEAK MIN ANNUAL 0%G 0 PERIODIC TEST TYPE STANDARD ANNUAL TEST FAIL ALARM DISABLED PERIODIC TEST FAIL ALARM DISABLED GROSS TEST FAIL ALARM DISABLED ANN TEST AVERAGING: OFF PER TEST AVERAGING: OFF TANK TEST NOTIFY: OFF T14K TST SIPHON BREAK:OFF DELIVERY DELAY : 15 MIN x, GOOD SAMARITAN 5201 WHITE LM 8MKERSFIELD 4A 10/21 /2011 12:37 Pm SUMP LEAK TEST REPORT DSLS TEST STARTED 12:22 PM TEST STARTED 10/21/2011 BEGIN LEUEL 3.0370 IN END TIME 12:37 PM END DATE 10/21/2011 ! END LEVEL 2.5295 IN LEAK THRESHOLD 0.002 IN TEST RESULT FAILED , f GOOD SAMARITAN 5201 WHITE LN BAKEPSFI£LD GA 10/21x2011 12:55 PM SUMP LM,' TEST REPORT DSLS TEST STARTED 12:40 PM TEST STARTED 10/21/2011 BEGIN LEUEL 2.9055 IN END TIME 12:55 PM END DATE tO/21/2011 END LEVEL 2.7619 IN LEAK THRESHOLD 0.002 IN TEST RESULT FAILED lz 4415 S LEAK TEST METHOD TEST ON DATE : ALL TANK APR 3, 1999 START TIME : 2:00 AM TEST RATE :0.20 GAL /HR DURATION 2 HOURS z LEAK TEST REPORT FORMAT E NORMAL t LIQUID SENSOR SETUP L 1 :DIESEL 2 A14NULAR TRI—STATE (SINGLE FLOAT) CATEGORY : ANNULAR SPACE L 2:DIESEL 2 SUMP TRI —STATE (SINGLE FLOAT) a CATEGORY : PIPING SUMP 6 EXTERNAL INPUT SETUP NONE OUTPUT RELAY SETUP ALARM HISTORY REPORT SENSOR ALARM L 1:DIESEL 2 ANNULAR ANNULAR SPACE FUEL ALARM JUN 2. 2010 11:21 AM FUEL ALARM JUN 2. 2010 11 :21 AM FUEL ALARM JUN 2, 2010 11:20 AM ALARM HISTORY REPORT SENSOR ALARM.---- - L2:DIESEL 2 SUMP PIPING SUMP FUEL ALARM DEC 18, 2010 5:54 PM FUEL ALARM JUN 2. 2010 10:24 AM FUEL ALARM JAN 18. 2010 2:58 PM MONITOR CERT. FAILURE REPORT SITE NAME: GOOD SAMARITAN ADDRESS: 5201 WHITE LANE CITY: BAKERSFIELD, CA REPAIRS: NONE PARTS INSTALLED: NONE DATE: 10 -21 -11 TECHNICIAN: RICH SIGNATURE: LAO 3 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.