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HomeMy WebLinkAbout420 34TH STREET (5)kd MONITORING SYSTEM CERTIFICATION For Use By All Jurisdictions Within the State 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_svggm control panel by the technician who perfonns 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 oftest date. A. General Information Facility Name: MEMORIAL HOSPITAL Bldg, No.: Site Address: 420 34T" ST. — - — City: BAKERSFIELD Zip: 93301 Facility Contact Person: RODNE Contact Phone No.: (661) 327 -4647 Make/Model of Monitoring System: TLS -350 INSP. ESTHER ON SITE Date ofTesting/Servicing: 4/16/2012 B. Inventory of Equipment Tested/Certified Check the approuriate boxes to indicatespecific eguipment 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). TankIIl:. Tank ID: In =Tank Gauging Probe. Model: In -Tank Gauging Probe. Model: AnnularSpace orVault Sensor. Model: Annular Space or Vault Sensor. Model: Piping Sump / Trench Sensor(s). Model: El 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: NO DISPENSERS 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 ca able generatin such reports, I have also attached a copy ofthe report; (check all that apply): ® System set -up ® Alarm report Technician Name (print): RICHIE PHILLIPS Signature: Certification No.: A29084 / 1035169 UT License. No.: C61/ D40 809850 Testing Company Name: RICH ENVIRONMENTAL Phone No.: (661) 326 -8442 Testing Company Address: 5643 BROOKS CT. BAKERSFIELD, CA 93308 Date ofTesdng/Servicing: 4/18/2011 Page 1 of 5 UN -036 —1 /4 www.unidocs.org Rev. 01/17/08 Monitoring System Certification D. Results of Testing/Servicing Software Version Installed: 127.04 rmmnlaoa +ha fnllnwina oh"Wief- N 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 p 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 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* N 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* F• N No Was liquid found inside any secondary containment systems designed as dry systems? (Check all that apply) Product; E] 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, ifapplicable N 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: SUCTION SYSTEM DOES NOT HAVE POSITIVE SHUTDOWN I. Page 2 of 5 UN-036 — 2/4 www.unidomorg Rev. 01/t7/08 Monitoring System Certification f F. In -Tank Gauging / SIR Equipment: E Check this box iftank gauging is used only for inventory control. Check this box if no tank gauging or SIR equipment is installed. This section ]rust 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 Section H, below, describe how and when these deficiencies were or will be corrected. G. Line Leak Detectors (LLD): rmmnlete the fnllnwina checklist- 0 Check this box ifLLDs 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? El. Yes. No* Was the testing apparatus properly calibrated? P 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 offif 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 p No* Were all items on the equipment manufacturer's maintenance checklist completed? An Section H, below, describe how and when these deficiencies were or will be corrected. Page 3 of 5 UN -036 — 3/4 www.unidomorg Rev. 01/17/08 SWRCB, January 2006 Spill Bucket Testing Report Form Thuform is intendedfor use by contractors performing annual testing of UST spill containment structures. The completedform and printoutsfrom tests (fapplicable), should be providedto thefacility owner /operatorfor submittal to the local regulatory agency. 1. FACILITY INFORMATION Facility Name: MEMORIAL HOSPITAL I Date of Testing: 4/16/12 Facility Address: 420 34 ST. BAKERSFIELD, CA. 93301 Facility Contact: RODGER SMITH Phone: (661)327 -4647 Date Local Agency Was Notified of Testing: Name ofLocal Agency Inspector (fpresent during testing): ESTHER 2. TESTING CONTRACTOR INFORMATION Company Name: RICH ENVIRONMENTAL Technician Conducting Test: RYAN MASON Credentials': CSLB Contractor X ICC Service Tech. SWRCB Tank Tester 0 Other (Specify) 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 0 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): 9:00 9:00 Initial Reading (RD: 12" 12" Test End Time (TF): 10:00 10:00 Final Reading (RF): 12" 12" Test Duration (TI: — Tj): HOUR 1 -HOUR. Change in Reading (RF - RO: 0 0 Pass/Fail Threshold or Criteria: 0.00 0.00 Test Result: X Pass Fail X Pass 0 Fail Pass 0 Fail 0 Pass 0 Fail Comments — (include information on repairs made prior to testing and recommendedfollow -upforfailed tests) CERTIFICATION OF TE NICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING I hereby certify that aft the informado ntained in this report is true, accurate, and infull compliance with legal requirements. Technician's Signature: Date: 4/16/12 State laws and regulations do not currently require testing to be performed by a qualified contractor. However, local requirements may be more stringent. YSTEM SECURITY SIPHON MANIFOLDED TANKS ODE : 000000 LIINEhPIANIFOLDED TANKS TR: NONE rAIdk. CHART SECURITY ISABLED L1ba t t00CUSTOMALARMSLEAKI11NPER1GDIC: DISABLED LEAK M IN „NNUAL 0'" Di. MASS/DENSITY SOFTWARE REVISION LEVEL DISABLED VERSION 127.04 PERIODIC TEST TYSTANDARDSOFTWAREu346127-100-2 CREATED - 07.02.06.11.02 NO SOFTWARE °iGDULE I FAILAPItdUALTESALARMDISABLED SYSTEM FEATURES: PERIODIC IN-TANK TESTS PERIODIC TEST FAIL ANNUAL IN -TANK TESTS ALARM DISABLED GROSS TEST FAILALARM DISABLED COMMUNICATIONS SETUP OFF FER (AVERAGIING: OFF TEST PORT 2ETTINC-2 : TANK TEST NOTIFY: OFF ' SYSTEM SETUP N014E FOUND TNK TST SIPHON gR£AI{ :OFF NPR 16. 2012 7: F ,0 AM DELIVERY DELAY 1 I MIN THRESHOLDpUMp RS -232 END OF MESSAGE SYSTEM UNITS DISABLED U.S. SYSTEM LANGUAGE ENGLISH SYSTEM DATE /TIME FORMAT MON DD YYYY HH:MM:SS xM BAKERSFIELD MEMORIAL HOSPITAL 420 34TH ST BAKERSF'IELD, CA-7' SHIFT TIME I : DISABLED IN -TANK SETUP _ - SHIFT TIME 2 : DISABLED SHIFT TIME 3 : DISABLED T 1:GEh1£kATOR TANKSHIFTTII -IE 4 : DISABLED PRODUCT CODE 1 TANK PER TST NEEDED WRN THERMAL COEFF :.000450 TANK DIAMETER : 127.00DISABfLED TANK ANN TST NEEDED WRN TANK PROFILE FULL VOL : 1 PT 20165DISABLED INE RE- ENABLE METHOD ASS LINE TEST FLOAT SIZE: 4,0 IN. INE PER TST NEEDED WRN WATER WARNING HIGH WATER LIMIT: 2.0 3.0ISABLED INE ANN TST NEEDED WRN ISABLED MAX OR LABEL VOL: 20168 OVERFILL LIMIT 90'/ PRINT TC VOLUMES NAEtLED HIGH PRODUCT 18151 95% 19159 Eh1P COMPENSATION DELIVERY LIMIT : 2006 VALUE (DEC F 1: 60.0 TICK HEIGHT OFFSET LOw,pRGDUCT 5000 IiSAGE: - 90% LEAK ALARM LIMIT: 99 99A'ZLIG: ASAVING TIME SUDDEN LOSS LIMIT: TANY. TILT 0.00 JISABLHT ISA$LED PROBE OFFSET 0.00 YSTEM SECURITY SIPHON MANIFOLDED TANKS ODE : 000000 LIINEhPIANIFOLDED TANKS TR: NONE rAIdk. CHART SECURITY ISABLED LEA]: TEST METHOD q b,., j T 2:80ILER TANK SENSOR PRODUCT CODE 2 TEST WEEKLY : ALL TANK L I :GENERATORA ' THERMAL COEFF :.000450 MON STP SUMP ^'P TANK DIAMETER : 127.00 START TIME : 12:00 All FUEL ALARM TANK PROFILE 1 PT TEST RATE :0.20 GAL/HR APR 16, 2012 8: 19 AMFULLVOL20168DURATION : 4 HOURS FUEL ALARM TST EARLY STOP:DISABLED APR 1S. 2011 12:12 PMFLOATSIZE: 4.0 IN. LEAK TEST REPORT FORMAT FUEL—ALARM WATER WARNING : 2.0 ENHANCED APR 18, 2011 12:11 pMHIGHWATERLIMIT: 3.0 MAX OR LABEL VOL: 2016E OVERFILL L,MIT 90%. 18151 HIGH PRODUCT 95% 19159 niARh1 HISTORY kEPORTDELIVERYLIMIT101/0 SENSOR2016I. 2:BOILR ----- SUhIPARMSTPSUMPLOWPRODUCT5000FUELALARMLEAKALARMLIMIT: 99 LIQUID SENSOR SETUP AFR 16, 8012SUDDENLOSSLIMIT: 99 8:16 AMTANKTILT0.00 FUEL ALARMPROBEOFFSET0.00 L 1 :GENERATOR SUMP APR 18, TRI -STATE (SINGLE FLOAT) 2011 12 :13 PMCATEGORY : STP SUMP FUEL ALAI;?pIIPHONGNIFOLDEDTANKSMAR31• °010TO: 8: 02 AMLINEMANIFOLDEDTA14KSL2:BOILER SUMP TO: NONE TRI -STATE (SINGLE FLOAT) CATEGORY : STP SUMP ALARM HISTORY REPORT LEAK MI14 PERIODIC: 0% SENSOR ALARM -- - 0 L 3:GENERATOR ANNULAR L 3:GENERATOR ANNULARNORIIALLYCLOSEDANNULARSPACELEAKMINANNUAL : 0•r. CATEGORY : ANNULAR SPACE FUEL ALARM0 , APR 16, 2512 8:20 AM PERIODIC TEST TYPE L 4:130ILER ANNULAR FUEL ALARM FEB 15, 2012 9:28 AllSTANDARDNORMALLYCLOSED CATEGORY ANNULAR SPACE FUEL ALARMANNUALTESTFAILAPR18. 2011 12:15 PMALARMDISABLED PERIODIC TEST FAIL ALARM DISABLED ALARM HISTORY REPORTGROSSTESTFAIL ALARM DISABLED SENSOR ALARM - - - -- L 4:BOI.LER ANNULARANNTESTAVERAGING: OFF ANNULAR SPACE PER TEST AVERAGING: OFF FUEL ALARM APR 16. 2012 8:20 AMTANKTESTPdOTIFY : OFF OUTPUT RELAY SETUP FUEL ALARM TNK TST SIPHON BREAK:OFF APR 16. 2012 7:58 AM DELIVERY DELAY 1 MIN FUEL ALARM PUMP THRESHOLD 10.00`/ FEB 15, 2012 9:26 AM MONITOR CERT. FAILURE REPORT SITE NAME: MEMORIAL HOSPITAL DATE: 4/16/12 THE FOLLOWING COMPONENTS WERE REPLACED/REPAIRED TO COMPLETE TESTING. REPAIRS • NONE LABOR: NONE PARTS INTALLED : NONE NAM: 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 OCCUR.ING FROM NON - COMPLIANCE. A COPY OF THIS DOCUMENT HAS BEEN LEFT ON -SITE FOR YOUR CONVIENENCE.