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Home My WebLink About430 CALIFORNIA AVENUE (4)MONITORING SYSTEM CERTIFICATION For Use By All Jurisdictions Within the Slate ofCalifornia 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 this date. A. General Information Facility Name: HP Go Go Site Address: 430 East California Avenue Facility Contact Person: Alondra Hernandez Make /Model of Monitoring System: Veeder -Root TLS -350 B. Inventory of Equipment Tested /Certified Check the appropriate boxes to indicate specific equipment Inspected /serviced: City: Bakersfield Bldg. No.: Zip: 93306 Contact Phone No.: 835 -8044 (0279) Date of Testing/Servicing: 4/7/2011 Tank ID: 10000 gal. Regular Tank ID: 10000 gal. Super U In -Tank Gauging Probe. Model: 847390 -107 x] In -Tank Gauging Probe. Model: 847390 -107 x] Annular Space or Vault Probe. Model: 794390-409 X] Annular Space or Vault Sensor. Model: 794390 -409 rx] Piping Sump / Trench Sensor(s). Model: 794380 -208 Piping Sump / Trench Sensor(s). Model: 794380 -208 U Fill Sump Sensor(s) Model: 794380 -208 X] Fill Sump Sensor(s). Model: 78380 -208 Lx I Mechanical Line Leak Detector. Model: STP -MAD X] Mechanical Line Leak Detector. Model: FX1y Electronic Line Leak Detector. Model: Electronic Line Leak Detector. Model: Cx1 Tank Overfill / High Level Sensor. Model: 794390 -107 U Tank Overfill / High Leval Sensor. Model: 794390 -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 1D: 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: D 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 x-1 Dispenser Containment Sensor(s). Model: 794380 -208 x] Dispenser Containment Sensor(s). Model: 794380 -208 X] Shear Valve(s). LX] Shear Valve(s). Dispenser Containment Float(s) and Chain(s). Dispenser Containment Float(s) and Chain(s) Dispenser ID: 5 & 6 Dispenser ID: Lx] Dispenser Containment Sensor(s). Model: 794380 -208 Dispenser Containment Sensor(s). Model: Lx] Shear Valve(s). Shear Valve(s). Dispenser Containment Float(s) and Chains(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). 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 varify that this information is correct and a plot plan showing the layout of monitoring equipment. For equipment capable of generating such reports, I have attached a copy of the report; (check all that apply) Q Systee Set -up Alarm history report Technician Name (print): Edward Mitchell Signature: ZM41 ( Certification No: B34472 License No: 804904 Testing Company Name: Confidence UST Services, Inc. Site Address: 430 East California Avenue, Bakersfield, Ca 93306 Phone No: 800- 339 -9930 Date of Testing/Servicing: 41712011 D. Results of Testing/Servicing Software Version Installed: Complete the following checklist: x] Yes No* Is the audible alarm operational? x Yes No* s e Visual alarm operational? x Yes 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 ifthe 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? U Sump/Trench Sensors [x:] Dispenser Containment Sensors Did you confirm positive shut -down due to leaks and sensor failure /disconnected? [x] Yes; No; U Yes No* For tank systems that utilize the monitoring system as the primary tank overfill warning device (i.e. no r] 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? 90 I % E Yes* No Was any monitoring equipment replaced? IfYes, identify specific sensors, probes, or other equipment replaced and list the manufacturer name and model for all replacement parts in Section E, below. Yes* U No Was liquid found inside any secondary containment systems designed as dry systems? Product; Water. If yes, describe causes in Section E, below. Tx N * 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: Premium Fill Spill Bucket failed. Replaced the Spill Bucket on Regular and the Fill Adapter on Regular Fill. F. In -Tank Guaging / SiR Equipment: [x] Check this box iftank 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: U 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? Ix Yes No* Was accuracy of system product level readings tested? Fxj Yes No* Was accuracy of system water level readings tested? x Yes No* Were all probes reinstalled properly? E 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: Cx] 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: 3 g.p.h.: 0.1 g.p.h.; 0.2 g.p.h.; x Yes No* Were all LLD's confirmed operational and accurate within regulatory requirments? x Yes No Was the testing apparatus properly calibrated? Yes No For mac anica 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 ifthe LLD detects a leak? x] N/A Yes 7 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 Lx] N/A malfunction or fails a test? Yes No* For electronic LLD's, have all accessible wiring connections been visually inspected? U N/A x Yes I ONo 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. H. Comments: HP 925 GO GO MARKET 430 E.CALIFORNIA AVE BAKERSFIELD CA 93304 661 -861 -8505 APR 7. 2011 1:12 PM SYSTEM STATUS REPORT T 1:DELIVERY NEEDED T 2:DELIVERY NEEDED HP 925 GO GO MARKET 430 E.CALIFORNIA AVE BAKERSFIELD CA 93304 661 -861 -8505 APR 7. 2011 1:13 PM SYSTEM STATUS REPORT T 1:DELIVERY NEEDED T 2 :1)EL I VERY NEEDED, INVENTORY REPORT T I.:PREM VOLUME - '739 GALS ULLAGE - 9413 GALS 90% ULLAGE- 8397 GALS TC VOLUME - 728 GALS HEIGHT - 12.04 INCHES WATER VOL - 0 GALS WATER - 0.00 INCHES TEMP - 80.5 DEG F T 2:UNLEADED VOLUME - 1743 GALS ULLAGE - 18406 GALS 903. ULLAGE- 16391 GALS TO VOLUME - 1727 GALS HEIGHT - 16.10 INCHES WATER VOL - 0 GALS WATER. - 0.00 INCHES TEMP - 72,8 DEG F 0 x w w W END x x x x x ALARM HISTORY REPORT SENSOR ALARM - - - -- L 1:1 -2 DISP DISPENSER PAN FUEL ALARM OCT 13. 2009 9:17 AM FUEL ALARM OCT 13. 2009 9:09 AM SENSOR OUT ALARM OCT 17. 2008 10:39 AM ALARM HISTORY REPORT SENSOR ALARM - - - -- L 2:3 -4 DISP DISPENSER PAN FUEL ALARM OCT 13. 2009 9 :18 AM SENSOR OUT ALARM. OCT 17. 2008 10:39 AM FUEL ALARM OCT 17. 2008 10:36 AM ALARM HISTORY REPORT SENSOR ALARM - - - -- L 3:5 -6 DISP DISPENSER PAN FUEL ALARM OCT 13, 2009 9:19 AM SENSOR OUT ALARM OCT 17,2008 10:39 AM FUEL ALARM OCT 17. 2008 10:38 AM ALARM HISTORY.REPORT SENSOR ALARM - - - -- L 4:91 FILL OTHER SENSORS FUEL ALARM FES 24. 2011 9:59 AM FUEL ALARM OCT 13, 2009 9:20 AM FUEL ALARM OCT 17. 2008 10:46 AM ALARM HISTORY REPORT SENSOR ALARM L 5:87 FILL OTHER SENSORS FUEL ALARM APR 3. 2011 9 :37 PM SETUP DATA WARNING MAR 22, 2011 6:46 AM FUEL ALARM MAR 20, 2011 6 :42 PM ALARM HISTORY REPORT SENSOR ALARM - - - -- L 6:91 STP STP SUMP FUEL ALARM FEB.24. 2011 9:56 AM FUEL ALARM OCT 13. 2009 9:22 AM SENSOR OUT ALARM OCT 17. 2008 10:39 AM ALARM HISTORY REPORT SENSOR ALARM L 7:91 ANN ANNULAR SPACE FUEL ALARM FEB 24. 2011 10:28 AM FUEL ALARM OCT 13 2009 9:24 AM 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 AM FUEL ALARM OCT 13. 2009 9:23 AM SENSOR OUT ALARM OCT 17. 2008 10:39 AM ALARM HISTORY REPORT SENSOR ALARM - - - -- L 9:87 ANN ANNULAR SPACE SENSOR OUT ALARM F£S 24. 2011 10:38 AM SENSOR OUT ALARM FES.24. 2011 10:33 AM FUEL. ALARM FEB 24. 2011 10:30 AM ALARM HISTORY REPORT SENSOR ALARM - - - -- L10: OTHER SENSORS ALARM HISTORY REPORT SENSOR ALARM - L11: OTHER SENSORS ALARM HISTORY REPORT SENSOR ALARM - - - -- L12 OTHER SENSORS ALARM HISTORY REPORT E[ENSOR ALARM - - - -- L13: OTHER SENSORS ALARM HISTORY REPORT SENSOR ALARM --- -- LI4: OTHER SENSORS ALARM HISTORY REPORT SENSOR ALARM - - - -- L15: OTHER SENSORS ALARM HISTORY REPORT SENSOR ALARM - - - -- L16: OTHER SENSORS SYSTEM SETUP APR 7. 2011 113 PM SYSTEM UNITS U.S. SYSTEM LANGUAGE ENGLISH SYSTEM DATE /TIME FORMAT MON DD YYYY HH:MM:SS xM HP 925 GO GO MARKET 430 E.CALIFORNIA AVE BAKERSFIELD CA 93304 661- 861 -8505 SHIFT TIME I : DISABLED SHIFT TIME 2 : DISABLED SHIFT TIME 3 : DISABLED SHIFT TIME 4 : DISABLED PERIODIC TEST WARNINGS DISABLED ANNUAL TEST WARNINGS DISABLED PRINT TC VOLUMES ENABLED TEMP COMPENSATION VALUE (DEG F f: 60.0 SYSTEM SECURITY CODE : 000000 COMMUNICATIONS SETUP PORT SETTINGS: NONE FOUND RS -232 SECURITY CODE : 000000 RS -232 END OF MESSAGE DISABLED 1N -TANK SETUP T I:PREM PRODUCT CODE. 1 THERMAL COEFF :.000700 DIAMETER 95•PTTANK TANK PROFILE FULL VOL 10152 FLOAT SIZE: 4.0 IN. 8496 i MATER WARNING 2.0 HIGH WATER LIMIT: 3.0 MAX OR LABEL VOL: 10152 OVERFILL LIMIT : g90y: HIGH PRODUCT 95U 9644 DELIVERY LIMIT 1105 LOW PRODUCT 500 99LEAKALARMLIMIT: SUDDEN LOSS LIMIT: 50 TANK TILT 0.00 p1ANIFOLDED TANKS Td: NONE DELIVERY DELAY 15 MIN T!2 :UNLEADED PRODUCT CODE. 2 THERMAL COEFF :.000700 TANK DIAMETER 113.75 TANK PROFILE 1 PT f FULL VOL 20149f SIZE: FLOAT 4.0 IN. 8496 WATER WARNING 2.0 HIGH WATER LIMIT: 3.0 MAX OR LABEL VOL: 20149 OVERFILL LIMIT 90% 1813 HIGH PRODUCT 19141 DELIVERY LIMIT 1031 2014 LOW PRODUCT 500 LEAK ALARM LIMIT: 99 SUDDEN LOSS LIMIT: 99 TANK TILT 0.00 MANIFOLDED TANKS TO: NONE DELIVERY DELAY : 15 MIN 1 LEAK TEST METHOD TEST ON DATE : ALL TANKfJAN1. 1996 START TIME : DISABLED TEST RATE :0.20 GAL /HR' DURATION : 2 HOURS LEAK TEST REPORT FORMAT NORMAL LIQUID SENSOR SETUP L 1:1 -2 DISP TRI -STATE (SINGLE FLOAT) CATEGORY : DISPENSER PAN L 2:3 -4 DISP - TRI -STATE (SINGLE FLOAT) CATEGORY : DISPENSER PAN L 3:5 -6 DISP TRI -STATE (SINGLE FLOAT) CATEGORY : DISPENSER PAN L 4:91 FILL TRI -STATE (SINGLE FLOAT) CATEGORY : OTHER SENSORS L 5 :.87 FILL TRI -STATE (SINGLE FLOAT) CATEGORY : OTHER SENSORS L 6:91 STP TRI -STATE (SINGLE FLOAT) CATEGORY : STP SUMP L 7:91 ANN TRI -STATE (SINGLE FLOAT) CATEGORY : ANNULAR SPACE L 8:87 STP TRI -STATE (SINGLE FLOAT) CATEGORY : STP SLOP L 9:87 ANN TRI -STATE (SINGLE FLOAT) CATEGORY : ANNULAR SPACE OUTPUT RELAY SETUP R 1:POSITIVE SHUT TYPE: STANDARD NORMALLY CLOSED LIQUID SENSOR ALMS ALL:FUEL ALARM ALL:SENSOR OUT ALARM 4 SENSOR ALARM - - - -- L 8:87 STP STP SUMP FUEL ALARM APR 7. 2011 1:14 PM SENSOR ALARM - - - -- L 8:87 STP STP SUMP FUEL ALARM APR 7, 2011 1:21 PM SENSOR ALARM - - - -- L 6:91 STP STP SUMP FUEL ALARM APR 7. 2011 1:22 PM SENSOR ALARM - - - -- L 7:91 ANN ANNULAR SPACE FUEL ALARM APR 7. 2011 1:23 PM SENSOR ALARM - - - -- L 7:91 ANN ANNULAR SPACE FUEL ALARM APR 7. 2011 1:24 PI-1 SENSOR ALARM -- - -- L 9:87 AN14 ANNULAR SPACE FUEL ALARM APR T. 2011 1:24 PM i -- - -- SYSTEM ALARM - - - -- PRINTER ERROR APR 7. 2011 1:31 P11 HP 925 GO GO MARKET 430 E.CALIFORNIA AVE BAKERSFIELD CA 93304 661 -861 -8505 APR 7, 2011 1:35 PM SYSTEM STATUS REPORT T 1:DELIV£RY NEEDED T 2:DELIVERY NEEDED HP 925 G0, GO MARKET 430 E XALIFORNIA AVE BAKERSFIELD CA 93304 661-861-8505 APR 7. 2011 1:35 PM SYSTEM STATUS REPORT T (:DELIVERY NEEDED T 2:DELIVERY NEEDED ALARM HISTORY REPORT SENSOR ALARM - - - -- L 1:1 -2 DISP DISPENSER PAN SENSOR OUT ALARM APR 7, 2011 1:30 PM FUEL ALARM APR 7 2011 1:25 PM FUEL ALARM OCT 13, 2009 9:17 AM ALARM HISTORY REPORT SENSOR ALARM - - - -- L 2:3 -4 DISP DISPENSER PAN SENSOR OUT ALARM APR '7. 201'1 1 :30 PM FUEL ALARM APR 7. 2911 1:27 PM FUEL ALARM OCT 13. 2009 9:10 NM u ALARM HISTORY REPORT SENSOR ALARM - - - -- L 3:5 -6 DISP DISPENSER PAN SENSOR OUT ALARM APR 7, 2011 1:30 PM FUEL ALARM APR 7. 2011 1:28 PM FUEL ALARM OCT 13, 2009 9:19 All ALARM HISTORY REPORT SENSOR ALARM - - - -- L 4:91 FILL OTHER SENSORS SENSOR OUT ALARM APR 7, 2011 1:30 PM FUEL ALARM APR 7. 2011 1:28 PM FUEL ALARM FEB 24. 2011 9:59 AM ALARM HISTORY REPORT SENSOR ALARM L 5:87 FILL OTHER SENSORS SENSOR OUT ALARM APR 7. 2011 1:30 PM FUEL ALARM APR 7, 2011 1:29 PM FUEL ALARM APR 3. 2011 9:37 PM ALARM HISTORY REPORT ALARM HISTORY REPORT SENSOR ALARM - ---- SENSOR ALARM - - --- L 6:91 STP L10: STP SUMP OTHER SENSORS ALARM HISTORY REPORT SENSOR OUT ALARM APR 7. 2011 1:30 PM SENSOR ALARM - - - -- L15: FUEL ALARM OTHER SENSORS APR 7. 2011 1 :22 PM FUEL ALARM FEB 24, 2011 9:56 All ALARM HISTORY REPORT 7-,SENSOR ALARM - - - -- L11 OTHER SENSORS ALARM HISTORY REPORT SENSOR ALARM - - - -- L16: OTHER SENSORS ALARM HISTORY REPORT SENSOR ALARM - -- -- L 7 :91 ANN ANNULAR SPACE SENSOR OUT ALARM ALARM HISTORY REPORT APR 7. 2011 1 :30 PM SENSOR ALARM - - - -- FUEL ALARM L12: APR 7. 2011 1:24 PM OTHER SENSORS ALARM HISTORY REPORT FUEL ALARM SENSOR ALARM - - - -- APR 7. 2011 1:23 PM L 1:1-2 DISP DISPENSER PAN SENSOR OUT ALARM APR 7. 2011 1:30 PM FUEL ALARM APR 7, 2011 1:25 PM ALARM HISTORY REPORT FUEL ALARM SENSOR ALARM - - - -- OCT 13. 2009 9:17 AM L13: ALARM HISTORY REPORT OTHER SENSORS SENSOR ALARM - - - -- L 8:87 STP STP SUMP SENSOR OUT ALARM APR 7. 2011 1 :30 PM FUEL ALARM APR 7. 2011 1:21 PM ALARM HISTORY REPORT FUEL ALARM APR 7, 2011 1:14 PM SENSOR ALARM - ---- L14: OTHER SENSORS ALARM HISTORY REPORT SENSOR ALARM - - - -- L 9:87 ANN ANNULAR SPACE FUEL ALARM APR, 7. 2011 1 :24 PM SENSOR OUT ALARM FEB 24.. 2011 10:38 F1M SENSOR OUT ALARM FEB 24. 2011 10:33 AM 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 printoutsfrom tests (ifapplicable), should be provided to thefacility owner /operatorfor submittal to the local regulatory agency. 1. FACILITY INFORMATION Facility HP Go Go Date of Testing: 4/7/2011 Facility Address: 430 East California Avenue, Bakersfield, Ca 93306 Facility Contact: Alondra Hernandez Phone: 835- 8044 /fax: (0279) Date Local Agency Was Notified of Testing: Name of Local Agency Inspector (ifpresent during testing): Ernie Medina 2. TESTING CONTRACTOR INFORMATION Company Name: Confidence ust service,inc. Technician Conducting Test: Edward Mitchell Credentials: El CSLB Contractor x ICC Service Tech. SWRCB Tank Tester Other (Spec) License Number(s): CSLB: 804904 ICC: 5474332702 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 Premium 3 4 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: 10.50" 10.50" Bucket Depth: 10.00" 10.00" Wait time between applying vacuum /water and start of test: 5 min 5 min Test Start Time (Tj): 1:30 pm 1:30pm Initial Reading (Rj): 9.00" 9.00" Test End Time (TF): 2:30pm 2:30pm Final Reading (RF): 9.00" 7.00" Test Duration (TF — Ti): 1 Hour 1 Hour Change in Reading (RF - Ri): 0.00" 2.00" Pass/Fail Threshold or Criteria: 0.0625" 0.0625" Test Result: Pass Fail Pass OO Fail Pass Fail Pass Fail 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 in full compliance with legal requirements Technician's Signature- _ Q Date: 4/7/2011 State laws and regulations do no t currently require testing to be performed by a qualified contractor. However, local requirements may be more stringent. 4O , OfID4 U fV CM 11 nMUKr Invoice No.: 26334 HP Go Go 430 East California Avenue Bakersfield, CA 93306 Repairs completed: Replaced Regular Fill Spill Bucket and Regular Fill Adapter Required Repairs, Still Pending: Premium Fill Spill Bucket needed to be replaced. Technician Name: Edward Mitchell Signature: - Date: 417/2011