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HomeMy WebLinkAbout420 34TH STREET (6)MONITORING SYSTEM CERTIFICATION For Use By All Jurisdictions Within the State ofCalifornia Authority Cited. Chapter 6.7, Health andSafety 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 pr ared 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 of test date. A. General Information Facility Name: MEMORIAL HOSPITAL Bldg. No.: Site Address: 420 34'" ST. City: BAKERSFIELD Zip: 93301 Facility Contact Person: RODGER SMITH Contact Phone No.: (661) 327 -4647 Make/Model of Monitoring System: TLS -350 INSP. ERNIE MEDINA ON -SITE Date of Testing/Servicing: 4118/2011 B. Inventory of Equipment Tested /Certified Cheek the appropriate boxes to indicate specific equipment inspected /serviced: Tank ID: DIESEL Tank ID: DIESEL In -Tank Gauging Probe. Model: MAG In -Tank Gauging Probe. Model: MAG Annular Space or Vault Sensor. Model: 420 Annular Space or Vault 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: 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: FLAPPER Other (specify equipment type and model in Section 'E on Page 2). Other (specify equipment type and model in Section E on Page 2). TanklD: Tank ED: 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 I 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: NO DISPENSERS Dispenser ID: Dispenser Containment Sensor(s). Model: Dispenser Containment Scnsor(s). Model: Shear Valve(s). Shear Valve(s). Dispenser Containment Float(s) and Chain(s). Dispenser Containment Float(s) and Chain(s). Dispenser JW 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). lf the facility contains more tanks or dispensers, copy this form. Include information for every tank and dispenser at the facility. C. Certification -1 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 uipment For any equipment capable of generating such reports, I have also attached a copy of the report; (check all that apply): System set -up ® tarm history report Technician Name (print): RYAN MASON Signature: Certification No.: A27367/ 8029371 -UT License. No.: 611 809850 Testing Company Name: RICH ENVIRONMENTAL Ph No.: (661) 32648402 Testing Company Address: 5643 BROOKS CT. BAKERSFIELD, CA 93308 Date of Testing/Servicing: 4118 /2011 Page 1 of 6 UN-036 —1/4 www.unidocs.org Rev. 01/17/08 qDgLa Monitoring System Certification D. Results of Testing/Servicing Software Version Installed: 127.04 Complete the foliowin 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? Ifso, at what percent of tank capacity does the alarm trigger? % 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* 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, if applicable Yes I 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. 1E. (Comments: Page 2 of 5 UN -036 — 2/4 www.unidoes.org Rev. 01117 /08 Monitoring System Certification F. In- Tank Gauging / SIR Equipment: L M D P_ Check this box if tank gauging is used only for inventory control. Check this box ifno 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: Q 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* 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): Comnlete 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 performance? N/A Check all that apply) Simulated leak rate: 3 g.p.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 Q 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? Q 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: Page 3 of 5 UN -036 — 3/4 www.unidoes.org Rev. 01/17/08 LkO i0 Monitoring System Certification Form: Addendum for Vacuum/Pressure Interstitial Sensors 16 11. Results of Vacuum/Pressure Monitoring Equipment Testing 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: NIA 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 Mow 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: NONE OF THESE SENSORS ARE PRESENT AT THIS SITE. Page 4 of 5 if the sensor successfully detects a simulated vacuum/pressure leak introduced in the interstitial space at the furthest point from thesensor, vacuum/pressure has been demonstrated to be communicating throughout the interstice. UN -036A - 1/1 www.unidomorg Rev. 01/26/06 UST Moultofing,,81te Plan itc Address. 420 34TH. ST BAKERVIELD, OX 03M, Date map was ,drawn: -Z,3—laU1. If you alr6dy have a dia that -shows WI irq- i bd " f ' tfi' with S'OUT'MonhOrin- uir in ortm on, )zu may inchkie J4 rather thanlWs page, Wg . . . ' 0ftan * an piji4 Cltw' iy: -dentfy. bcati6js bNbeAbIkIw1jig equipment, installed: yjo6jt— sy teT 00tedl p s;:s&M Yhdfiif6rink tank annular spkcs sumps, dispenser 02is, spill container, 6r 60w. sebbndiaiti- ' ' 4" arew' h - - t6rk - Ai iqnid,level vmhesfif wd fvr leak delecti6h). it the q%ci Ordvid %n te the'date, WW. S1tb`:P1itn 1— M prq L N4*b - 414 www.uaWomorg Rev. 01 /1 7MB. Y, k° rl, SWRCB, January 2006 Spill Bucket Testing Report Form Thisform is intendedfor use by contractors performing annual testing ofUST 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 Name: MEMORIAL HOSPITAL Date ofTesting: 4/18/11 Facility Address: 420 34 ST. BAKERSFIELD, CA. 93301 Facility Contact: RODGER SMITH Phone: (661)327 -4647 Date Local Agency Was Notified ofTesting: Name of Local Agency Inspector (tfpresent during testing): ERNIE MEDINA 2. TESTING CONTRACTOR INFORMATION Company Name: RICH ENVIRONMENTAL Technician Conducting Test: RYAN MASON Credentials: CSLB Contractor X ]CC Service Tech. SWRCB Tank Tester Other (Spec) License Number(s): 8029371 -UT 3. SPILL BUCKET TESTING INFORMATION Test Method Used: X Hydrostatic Vacuum Other Test Equipment Used: VISUAL Equipment Resolution: 0 Identify Spill Bucket (By Tank Number, Stored Product, etc) 1 DIESEL WEST 2 DIESEL EAST 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" 12" Bucket Depth: 14" 14" Wait time between applying vacuum/water and start oftest: 30 MIN 30 MIN Test Start Time (Tj): I :OOPM 1:OOPM Initial Reading (R,): 12" 12" Test End Time (TF): 2:OOPM 2:OOPM Final Reading (RF): 12" 12" Test Duration (TF — T[): 1 -HOUR 1 -HOUR Change in Reading (RF - RJ: 0 0 Pass/Fail Threshold or Criteria: 0.00 0.00 r r^riln'i r i Z p I 1 rrU Comments —(include information on repairs madeprior to testing, andrecommendedfollow -upforfailed tests) CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING 1 hereby certify that all the information contained in this report Is true, accurate, and in full compliance with legal requirements. Technician's Signature: Date: 4/18/11 State laws and regulations do r o currer l+ require testing to be performed by a qualified contractor. However, local requirements may be more stringent. v SYSTEM SECURITY CODE : 000000 TANK CHART SECURITY DISABLED CUSTOM ALARMS DISABLED LAU -6 Lv IN —TANK SETUP T 2:BOILER TANK PRODUCT CODE 2 THERMAL COEFF :.000450 T 1 :GENERATOR TANK TANK DIAMETER 127.00 SOFTWARE REVISION LEVEL PRODUCT CODE 1 TANK PROFILE 1 PT VERSION 127.04 THERMAL COEFF :-000460 FULL VOL 20168 SOFTWARE# 346127 -100 -E TANK DIAMETER 127.00 CREATED - 07.02,06.J1.02 TANK PROFILE 1 PT FULL VOL 20168 FLOAT SIZE: 4.0 IN. 140 SOFTWARE MODULE WATER WARNING 2.0SYSTEMFEATURES: PERIODIC IN -TANK TESTS FLOAT SIZE: 4.0 IN. HIGH WATER LIMIT: 3.0 ANNUAL IN -TANK TESTS WATER WARNING 2.0 MAX OR LABEL VOL: 20168 HIGH WATER LIMIT: .3.0 OVERFILL LIMIT 9cr/o 18151 MAX OR LABEL VOL: 20168 HIGH PRODUCT 951% OVERFILL LIMIT 90 19159 ti DELIVERY LIMIT a,. -.`151 HI 'RUDUCT - 2006CI" 19159 DELIVER`: LIMIT 10% LOW PRODUCT 5000 2016 LEAK ALARM LIMIT: 99 SYSTEM SETUP SUDDEN LOSS LIMIT: 99 LOW PRODUCT 5000 TANK TILT U.00 APR 18, 2011 12:58 PM LEAK. ALARM LIMIT: 99 PROBE OFFSET 0.00 SUDDEN LOSS LIMIT: 99 TANK TILT 0.00 PROBE OFFSET 0.00 SIPHON 1'"NIFOLDED TANKS SYSTEM UNITS T#: NONE LINE MANIFOLDED TANKSU.S. SYSTEM LANGUAGE SIPHON MANIFOLDED TANKS T #: NONE ENGLISH T#: NONE SYSTEM DATE /TIME FORMAT LINE MANIFOLDED TANKS MON DD YYYV HH :I'IM :SS xM T #: P40NE LEAK M114 PERIODIC: 0/ 0 BAKERSFIELD MEMORIAL HOSPITAL LEAK MIN PERIODIC: 0'/ LEAK MIN ANNUAL : 0'i 420 34TH ST 0 0 BAKERSFIELD, CA LEAK FII1V ANNUAL 0% SHIFT TIME 1 DISABLED 0 PERIODIC TEST TYPE SHIFT TIME 2 DISABLED STANDARD SHIFT TIME 3 DISABLED SHIFT TIME 4 DISABLED PERIODIC TEST TYPE ANNUAL TEST FAIL STANDARD ALARM DISABLED TANK PER TST 14EEDED WRN DISABLED ANNUAL TEST FAIL PERIODIC TEST FAIL TANK ANN TST NEEDED WRN ALARM DISABLED ALARM DISABLED DISABLED. PERIODIC TEST FAIL GROSS TEST FAIL LINE RE-ENABLE METHOD ALARM DISABLED ALARM DISABLED PASS LINE TEST GROSS TEST FAIL ANN TEST AVERAGING: OFF LINE PER TST NEEDED WRN ALARM DISABLED PER TEST AVERAGING: OFF DISABLED LINE ANN TST NEEDED WRN ANN TEST AVERAGING: OFF TANK TEST NOTIFY: OFF DISABLED PER TEST AVERAGING: OFF TNK TST SIPHON BREAK:OFF PRINT TO VOLUMES TANK TEST NOTIFY: OFF ENABLED DELIVERY DELAY 1 MIN TNK TST SIPHON BREAK:OFF PUMP THRESHOLD 10.00% TEMP COMPENSATION VALUE (DEG F ): 60.0 DELIVERY DELAY 1 MIN STICK HEIGHT OFFSET PUMP THRESHOLD 10.00% DISABLED ULLAGE: 90% DAYLIGHT SAVING TIME DISABLED SYSTEM SECURITY CODE : 000000 TANK CHART SECURITY DISABLED CUSTOM ALARMS DISABLED LEAK TEST METHOD TEST WEEKLY : ALL TANK MON TART TIME : 1'2:00 AM TEST RATE :0.20 GAL /HR DURATION : 4 HOURS TST EARLY STOP:DISABLED LEA: TEST REPORT FORMAT ENHANCED LIQUID SENSOR SETUP L I :GENERATOR 01JMP TRI -STATE (SINGLE FLOAT) CATEGORY : STP SUMP L 2 :BOILER SUMP TRI -STATE (SINGLE FLOAT) CATEGORY : STP SUMP L 3:GENERATOR ANNULAR NORMALLY CLOSED CATEGORY : AWULAR SPACE r. L 4:BOILER ANNULAR NORMALLY CLOSED CATEGORY : ANNULAR SPACE OUTPUT RELAY SETUP LOW TEMP WARNING OCT 19, 2010 10:03 AM L}u 14 UALARMRISTORYREPORTALARMHISTORYREPORT . SYSTEM ALARM - - -- PAPER OUT SENSOR ALARM - - --- SEP 14, 2010 6:50 AM L 1 :GENERATOR SUMP PRINTER ERROR. STP SUMP SEP 14. 2010 8:50 AM FUEL ALARM APR 18, 2011 12 :12 PM FUEL ALARM APR 18. 2011 12:11 1>11 FUEL ALARM APR 18, 2011 12:11 PM ALARM HISTORY REPORT SENSOR ALARM - - - -- L 2:90ILER SUMP STP SUMP FUEL ALARM APR 18, 2011 12:13 PM FUEL ALARM MAR 31, 2010 8:02 AM ALARM HISTORY REPORT IN -TANK ALARM --- -- FUEL ALARM MAR 4. 2009 9:21 AM T I :GENERATOR TANK PROBE OUT v OCT 19, 2010 9:54 AM riLARI °1 HISTORY REPORTOCT5. 2010 12:45 PM SEP48OR ALARM ----- LOW TEMP WARNING L 3:GENERATOR ANNULARANNULARSPACEOCT19. 2010 1 :12 PM FUEL ALARM APR 18. 2011 12:15 PM FUEL ALARM SEP 14, 2010 8 :44 AM FUF,L ALARM SEP 14, 2010 8:35 AM t END R ALARM HISTORY REPORT SENSOR ALARM - - - -- L 4:13OILER ANNULARANNULARSPACE FUEL ALARM APR I8, 2011 12:15 PM FUEL ALARM ALARM HISTORY REPORT MAR 31, 2010 B:O9 AM IN -TANK ALARM - - - -- FUEL 3IALARM MAR _010 8:06 AMT2:130ILER TANK PROBE OUT OCT 19, 2010 6:40 AM LOW TEMP WARNING OCT 19, 2010 10:03 AM LWO t. MONITOR CERT. FAILURE REPORT SITE NAME : MEMORIAL HOSPITAL DATE: 4 /18/11 TH THE FOLLOWING COMPONENTS WERE REPLACED/REP REIN' O COMPLETE TESTING. (J V REPAIRS: NONE LABOR: NONE PARTS INTALLED : 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 CONV ENENCE.