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Home My WebLink About430 CALIFORNIA AVENUE (5)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 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 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: HP Go -Go Site Address: 430 E. California Avenue Facility Contact Person: Alondra Make /Model of Monitoring System: Veeder Root TLS 350 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate speciric equipment inspected/serviced: Bldg. No.: City: Bakersfield Zip: 93304 Contact Phone No.: (661) 835 -8044 Date of Testing/Servicing: 2/24 /2011 Tank ID: 1 unleaded Tank ID: 2 supreme Z In= lank Gauging Probe. Model: 847390 -309 Z In= Tank Gauging Probe. Model: 847390 -309 N Annular Space or Vault Sensor. Model: 794390 -420 Z Annular Space or Vault Sensor. Model: 794390 -420 N Piping Sump /Trench Sensor(s). Model: 794380 -208 Z Piping Sump/ Trench Sensor(s). Model: 794380 -208 Fill Sump Sensor(s). Model: Fill Sump Sensor(s). Model: N Mechanical Line Leak Detector. Model: FX1 V Z Mechanical Line Leak Detector. Model: FX1 V Electronic Line Leak Detector. Model: Electronic Line Leak Detector. Model: N "Tank Overfill / High -Level Sensor. Model: 847390 -309 Z Tank Overfill / High -Level Sensor. Model: 847390 -309 Other (specify equipment type and model in Section E on Page 2). 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 Deteotor. 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 4 Dispenser ID: Dispenser ID: Dispenser Containment Sensor(s). Model: Dispenser Containment Sensor(s). Model: Shear Valve(s). Shear Valve(s). Dispenser Containment Floa(s) and Chain(s). Dispenser Containment Float(s) and Chain(s). Dispenser ID: Dispenser ID: Dispenser Containment Sensor( -). Model: Dispenser Containment Sensor(s). Model: Shear Valve(s). Shear Valve(s). Dispenser Containment Flout(s) and Cham(.$). Dispenser Containment Floats) 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 F7oat(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 of the report; (check all that apply): ® System set -up ® Alarm history report Technician Name (print): Jerry Rangel Signature: Certification No.: ICC# 5309489 -UT V/R #B35460 License. N .. 5328 A -haz Testing Company Name: Redwine Testing Services, Inc. Phone No.: (661) 834 -6993 Site Address: .P.O. Box 1567, Bakersfield. CA. 93302 Page 1 of 3 Date of Testing/Servicing: 2/24 /2011 Monitoring System Certification D. Results of Testing/Servicing Software Version Installed: 14.01 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. If yes, describe causes in Section E, below. Yes No* Was monitoring system set -up reviewed to ensure proper settings? Attach setup reports, if applicable Yes No* 1 Is all monitoring equipment operational per manufacturer's specifications? V In Section E below, describe how and when these deficiencies were or will be corrected. E. Comments: The monitor was reprogrammed for sensor out. UDC sensors were not tested due to access issues. There is no overfill alarm outside the building (no flappers on the drop tubes either). Page 2 of 3 Mohitoring System Certification F. In -Tank Gauging / SIR Equipment: N 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): Complete the following checklist: Check this box if LLDs are not installed. Yes No* For equipment start -up or annual equipment certification, was a leak simulated to verify LLD perfonnance? N/A Check all that apply) Simulated leak rate: 3 g.p.h.; 0.1 g.p.h ; [10.2 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* Foi- 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 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 the Section H, below, describe how and when these deficiencies were or will be corrected. H. Comments: LLDs re not tested at this time due to across iss gg, Page 3 of 3 Spill Bucket Testing Report Form SWRCB, January 2006 Thisform is intended for use by contractors performing annual testing of USTspill containment structures. The completedform and printouts from tests (if applicable), should be provided to thefacility owner /operator for submittal to the local regulatory agency. 1. FACILITY INFORMATION Facility Name: HP Go -Go I Date of Testing: 02/24/11 Facility Address: 430 E. California Ave, Bakersfield, CA 93304 Facility Contact: Alondra Phone: 661 - 835 -8044 Date Local Agency Was Notified of Testing : 02/10/11 Name of Local Agency Inspector (ifpresent during testing): 2. TESTING CONTRACTOR INFORMATION Company Name: Redwine Testing Services, Inc. Technician Conducting Test: Jerry Rangel Credentials': CSL.B Contractor ICC Service Tech. SWRCB Tank Tester Other (Specifi,) License Number(s): Contractors Lic. 532878 A -Haz ICC# 5309489 -UT 3. SPILL BUCKET TESTING INFORMATION Test Method Used: Hydrostatic Vacuum Other Test Equipment Used: INCON TS -STS Equipment Resolution: 0.0000 in. Identify Spill Bucket (BY Tank Number, Stored Product, etc.) UNL 87 FILL UNL 87 VAPOR UNL 91 FILL UNL 91 VAPOR Bucket Installation Type: Direct Bury Contained in Sump Direct Bury Contained in Sump Direct Bury Contained in Sump Direct Bury Contained in Sum Bucket Diameter: 11 l I 11 11 Bucket Depth: 10 11 131/2 13 1/2 Wait time between applying vacuum/water and start of test: 30 min 30 min 30 min 30 min Test Start Time (Ti): 9:30 am 9:30 am 9:30 am 9:30 am Initial Reading (R,): N/A 81/4 8'/2 93/4 Test End Time (T,:): 10:30 am 10:30 am 10:30 am 10:30 am Final Reading (Rr): N/A 8 3/ 8' /s 93/4 Test Duration (TF — Tt): 1 hour 1 hour 1 hour 1 hour Change in Reading (RF -R,): N/A None None None Pass/Fail Threshold or Criteria: No Drop in level No Drop in level No Drop in level No Drop in level Test: Result Pass X Fatl X;tP,ass" Fatl'' X Pass Fail;; , X Pass; Fail ` Comments — (include information on repairs made prior to testing, and reconT.mendedfollow -up forfailed tests) 87 fill bucket is a visual failure, fill adaptor is not sealed to the fill riser. 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 Signa Date:_02 /24/ 11 State laws and regulations do not currently require testing to be performed by a qualified contractor. However, local requirements may be more stringent. SYSTEM SETUP FEB 24, 2011 10:39 AM SYSTEM UNITS U.S SYSTEM LANGUAGE ENGLISH SYSTEM DATE 'TIME F,`Rt "lAT MON DD YYYY HH :111: SS xt °1 HP 925 GO GO MARKET 430 E.CALIFORNIA AVE BAKERSFIELD CA 93304 661 - 861 -8505 SHIFT TIME 1 DISABLED SHIFT TIME 2 DISABLED S H I FT TI 11E :3 : DISABLED SHIFT TIME 4 DISABLED PERIODIC TEST WARNINGS DISABLED ANNUAL TEST WARNINGS DISABLED PRINT TC VOLUI,IE ENABLED TEMP COMPENSATION VALUE (DEG F ): 60.0 SYSTEM SECURITY CODE : 000000 LEAK TEST t °IETHoD TEST ON DATE : ALL TANK JAN 1, 1996 START TIME : DISABLED TEST RATE :0.20 GAL!HR DURATION . 2 HOURS LEAK TEST REPORT FORMAT NORMAL LIQUID SENSOR SETUP IN-TANK SETUP - - - - - - - - - - - - L 1:1 -2 DISP TRI -STATE (SINGLE FLOAT) T I:PREM CATEGORY : DISPENSER PAN PRODUCT CODE 1 THERMAL COEFF :.000700 TANK DIAMETER 95.75 TANI' PROFILE 1 PT L 2:3-4 'DISP FULL VOL 10152 TRI -STATE (SINGLE FLOAT) CATEGORY : DISPENSER PAN FLOAT SIZE: 4.0 I IV 8496 L 8:87 STP WATER WARNING 2.0 L 3:5 -6 DISP HIGH WATER. LIt "IIT: 3.0 TRI -STATE (SINGLE FLOAT) OVERFILL LIMIT CATEGORY : CATEGORY : DISPENSER PAN MAX. OR LABEL VOL: 10152 OVERFILL LIMIT 90% 913E TANK DIAMETER HIGH PRODUCT 95% L 4:91 FILL TANK PROFILE 9644 TRI- STATE (SINGLE FLOAT) DELIVERY LIMIT 10 %. CATEGORY : OTHER SENSORS CATEGORY : 1015 R 1:POSITIVE SHUT LOW PRODUCT 500 TYPE: LEAK ALARM LIMIT: 99 L 5:87 FILL SUDDEN LOSS LIMIT: 50 TRI -STATE (SINGLE FLOAT) TANK TILT 0.00 CATEGORY : OTHER SENSORS MANIFOLDED TANKS T #: NONE LIQUID SENSOR ALMS DELIVERY DELAY : 15 1.11N L 6:91 STP DELIVERY DELAY : 15 I'll N TRI -STATE (SINGLE FLOAT) CATEGORY : STP SUI "IP L 7:91 ANN TRI -STATE (SINGLE FLOAT) CATEGORY : ANNULAR SPACE FLOAT SIZE: 4.0 IN. 8496 WATER WARNING 2.0 L 8:87 STP HIGH WATER LIh9IT: 3.0 TRI -STATE SINGLE FLOAT) T 2:UNLEADED OVERFILL LIMIT CATEGORY : STP SUMP PRODUCT CODE 18134 HIGH PRODUCT THERMAL COEFF :.000700 19141 TANK DIAMETER 113.75 L 9:87 ANN TANK PROFILE 1 PT TRI -STATE SINGLE FLOAT) FULL VOL 20149 CATEGORY : ANNULAR SPACE FLOAT SIZE: 4.0 IN. 8496 WATER WARNING 2.0 HIGH WATER LIh9IT: 3.0 MAX OR LABEL VOL: 20149 OVERFILL LIMIT 90% 18134 HIGH PRODUCT 95% 19141 DELIVERY LIMIT 101/0 2014 OUTPUT RELAY SETUP LOW PRODUCT 500 LEAK ALARM LIMIT: 99 R 1:POSITIVE SHUT SUDDEN LOSS LIMIT: 99 TYPE: TANK, TILT 0.00 STANDARD NORMALLY CLOSED MANIFOLDED TANKS T #: NONE LIQUID SENSOR ALMS DELIVERY DELAY : 15 1.11N ALL:FUEL ALARM ALL:SENSOR OUT ALARM ALARM HISTORY REPORT SYSTEM ALARM PAPER OUT FEB 11, 2011 9:02 All PRINTER ERROR FEB 1 1 , 2011 9:02 AP9 BATTERY IS OFF JAN 1, 1996 8:00 All. ALARM HISTORY REPORT I N- TAr0JK ALARM - T 1:PREM SETUP DATA WARNING ALARM JAN 1. 1996 8:58 Arl OVERFILL ALARRll 2005 FEB 24, 2011 9:42 All LOW PRODU, T LHRr °I FEB 24, FEB 7. 0 1 1 r: i' :; F P9 JAN 201 1 1 '_ : ii Fr1 DEC ilir= PM 1'P'i HIGH PRODUCT 12:15 ALARM FEB 10, FEB 24, 2011 9:42 AM INVALID FUEL LEVEL FEB 24. FEB '24. 2011 9:41 All FEB 7. 2011 6:09 PM JAN 29, 2011 5:56 PNl PROBE OUT FEB 24, 2011 9:40 AN JAN 1, 1996 8:59 All JAN 1, 1996 8:32 All DELIVERY NEEDED FEB 24, 2011 9:40 All FEB 17, 2011 3:22 PM FEB 8. 2011 11:18 All MAX PRODUCT ALARM FEB 24. 2011 9:42 All ALARM HISTORY REPORT IN-TAN}; ALARM - T :UNLEADED OVERFILL ALARM FEB 24, 2011 9:44 All NOV 17, 2005 4:44 PM HIGH PRODUCT OCT 17, 2008 ALARM FUEL ALARM FEB 24, 2011 9:44 All INVALID FUEL LEVEL FEB 17, 2011 3:05 PM FEB 14, 2011 12:15 PM FEB 10, 2011 1:53 P11 PROBE OUT FEB 24. 2011 9:39 All DELIVERY NEEDED FEB 22, 2011 8:01 P11 FEB 16, 2011 4:32 PM FEB 13, 2011 10:43 All MAX PRODUCT ALARM FEB 24, 2011 9:44 All ALARM HISTORY REPORT SENSOR ALARM:---- - L 1:1 -2 DISP DISPENSER PAN FUEL ALARM OCT 13, 2009 9:17 All FUEL ALARM OCT 13, 2009 9:09 All SENSOR OUT ALARM OCT 17, 2006 10:39 All ALARM HISTORY REPORT SENSOR ALARM _ - - -- L 2:3 -4 DISP DISPENSER PAN FUEL ALARM OCT 13, 2009 9:18 All SENSOR OUT ALARM OCT 17, 2008 10:39 AM FUEL ALARM OCT 17, 2008 10:38 All ALARM HISTORY REPORT SENSOR ALARM - - - -- L 3:5 -6 DISP DISPENSER PAN FUEL ALARM OCT 13, 2009 9:19 All SENSOR OUT ALARM OCT 17, 2008 10:39 AM FUEL ALARM OCT 17, 2008 10:38 All ALARM HISTORY REPORT SENSOR ALARM - - - -- L 4:91 FILL OTHER SENSORS FUEL ALARM FEB 24, 2011 9:59 All FUEL ALARM OCT 13, 2009 9:20 AM FUEL ALARM OCT 17, 2008 10:46 All ALARM HISTORY REPORT SENSOR ALARM - - - -- L 5:87 FILL OTHER SENSORS FUEL ALARM FEB 24, 2011 9:52 AM SETUP DATA WARNING DEC. 18, 2010 5:38 PM FUEL ALARM DEC 18, 2010 4:17 PM ALARM HISTORY REPORT SENSOR ALARM - - - -- L 6:91 STP STP SUMP FUEL ALARM FEB '24, 2011 9:56 All FUEL ALARM OCT 13, 2009 9:22 All SENSOR OUT ALARM OCT 17, 2008 10:39 AM ALARI"1 HISTORY REPORT SENSOR ALARM - - - -- L 7:91 ANN ANNULAR SPACE FUEL ALARM FEB 24, 2011 10:28 All FUEL ALARM OCT 13, 2009 924 All SENSOR OUT ALARM OCT 17, 2008 10 :39 AM ALARM HISTORY REPORT SENSOR ALARM - - - -- L 8:87 STP STP SUMP FUEL ALARM FEB 24, 2011 9:54 APM FUEL' ALARM OCT 13, 2009 9 :23 AM SENSOR OUT ALARH OCT 17, 2008 10 :39 Al ALARM HISTORY REPORT SENSOR ALARM - - - -- L 9:87 ANN ANNULAR SPACE SENSOR OUT ALARM FEB 24, 2011 10:38 AM SENSOR OUT ALARM FEB 24, 2011 10:33 All FUEL ALARM FEB 24, 2011 10:30 All ALARM HISTORY REPORT SENSOR ALARM - - - -- L10: OTHER SENSORS