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HomeMy WebLinkAbout13004 STOCKDALE HWY (8)MONITORING SYSTEM CERTIFICATION L / 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 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: CHEVRON Site Address: 13004 STOCKDALE HVVY City: BAKERSFIELD Facility Contact Person: KHENG CHOA Make/Model of Monitoring System: TLS -350 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected /serviced: Contact Phone No.: Bldg. No.: Zip: Date of Testing/Servicing: 4/17/2012 Tank ID: UNL87 Tank ID: PLUS 89 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: FX1V Mechanical Line Leak Detector. Model: FX1V 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). Tank ID: PREM 91/SPLIT Tank ID: DIESELISPLIT In -Tank Gauging Probe. Model: MAG In -Tank Gauging Probe. Model: MAG Annular Space or Vault Sensor. Model: 4201SPLIT Annular Space or Vault Sensor. Model: 420 /SPLIT Piping Sump / Trench Sensor(s). Model: 208 Piping Sump / Trench Sensor(s). Model: 20a Fill Sump Sensor(s). Model: Fill Sump Sensor(s). Model: Mechanical Line Leak Detector. Model: FX1V Mechanical Line Leak Detector. Model: FX1DV 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: 1 -2 Dispenser ID: 3-4 Dispenser Containment Sensor(s). Model: 406 10 Dispenser Containment Sensor(s). Model: 406 Shear Valve(s). Shear Valve(s). Dispenser Containment Float(s) and Chain(s). Dispenser Containment Float(s) and Chain(s). Dispenser ID: 5-6 Dispenser ID: 7-8 Dispenser Containment Sensor(s). Model: 406 Dispenser Containment Sensor(s). Model: 406 Shear Valve(s). Shear Valve(s). Dispenser Containment Float(s) and Chain(s). Dispenser Containment Floats) and Chain(s). penser ID: 9 -10 Dispenser ID: 1000111 ispenser Containment Sensor(s). Model: 406 Dispenser Containment Sensor(s). Model: hear Valve(s). Shcar Valve(s). Dispenser Containment Floats) 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 erating such reports, I have also attached a copy ofthe report; (check all that apply): ® System set -up ® Alarm his report Technician Name (print): RICH PHILLIPS Signature: Certification No.: A2908411035169 -UT License. No.: C61/ D40 809850 Testing Company Name: RICH ENVIRONMENTAL Phone No.: (661) 392 -8687 Testing Company Address: 5643 BROOKS CT. BAKERSFIELD, CA 93308 Date ofTesting/Servicing: 4/1712012 Page 1 of 5 UN -036 —1/4 www.unidocs.org Rev. 01/17/08 Monitoring System Certification 4/ /jy D. Results of Testing/Servicing Software Version Installed: 329.01 Complete the following checklist: Yes I 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 R 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) R 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? Ifyes: 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 oftank capacity does the alarm trigger? % Yes* R 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. R 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 set up reports, if applicable Yes 1 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: PUMP WATER OUT OF UDC #3-4 SB989 REPAIR ARE UNDERWAY AT THIS SITE Page 2 of 5 UN4036 — 2/4 www.unidocs.org Rev. 01/17108 Monitoring System Certification F. In -Tank Gauging / SIR Equipment: Check this box iftank 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: 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? p Yes 1 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): Cmmnlete the fnllnwino eheeklirat- 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 ; [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* 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 ifany portion ofthe monitoring system malfunctions N/A or fails a test? p 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 A, below, describe how and when these deficiencies were or will be corrected. H. Comments: REPL _GEO_8,q_LEA1( DETECTORAVO IRE TEST UN -036 - 314 Page 3 of 5 www.unidocs.org Rev. 01/17/08 woo r. 4 T. V. 01 75: 90 I. 7&1 '4 t RICH ENVIRONMENTAL 5643 BROOKS CT. BAKERSFIELD, CA. 93308 OFFICE (661)392 -8687 FAX (661)392 -0621 PRODUCT LINE LEAK DETECTOR TEST WORK SHEET FACILITY NAME: CHEVRON FACILITY ADDRESS: 13004 STOCKDALE HWY, BAKERSFIELD, CA 93314 PRODUCT LINE TYPE: PRESSURE PRODUCT LEAK DETECTOR TYPE TEST TRIP PASS BELOW P.S.I. OR SERIAL NUMBER 3 G.P.H. FAIL UNL87 L/D TYPE: RED JACKET YES 11 PASS SERIAL # MECHANICAL PLUS89 L/D TYPE: RED JACKET 12 NO FAIL SERIAL # MECHANICAL _ PREmq1 LID TYPE: RED JACKET _ YES PASS SERIAL # MECHANICAL 12 DIESEL 10 LID TYPE: RED JACKET YES PASS SERIAL # MECHANICAL I CERTIFY THE ABOVE TESTS WERE CONDUCTED ON THIS DATE ACCORDING TO RED JACKET PUMPS FIELD TEST APPARATUS TESTING PROCEDURE AND LIMITATIONS. THE MECHANICAL LEAK DETECTOR TEST PASS / FAIL IS DETERMINED BY USING A LOW FLOW THRESHOLD TRIP RATE OF 3 GALLONS PER HOUR OR LESS AT 10 P.S.I. I ACKNOWLEDGE THAT ALL DATA COLLECTED IS TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE. TECHNICIAN: RICH PHILIAfs SIGNATURE: DATE: 417 -12 G 1Gy RICH ENVIRONMENTAL 5643 BROOKS CT. BAKERSFIELD, CA. 93308 OFFICE (661)392 -8687 FAX (661)392 -0621 PRODUCT LINE LEAK DETECTOR TEST WORK SHEET FACILITY NAME: CHEVRON FACILITY ADDRESS: 13004 STOCKDALE HWY, BAKERSFIELD, CA 93314 PRODUCT LINE TYPE: PRESSURE PRODUCT LEAK DETECTOR TYPE TEST TRIP PASS BELOW P.S.I. OR SERIAL NUMBER 3 G.P.H. FAIL LNL89 L/D TYPE: RED JACKET YES 10 PASS SERIAL # MECHANICAL L/D TYPE: _ YES PASS SERIAL # _ NO FAIL L/D TYPE: _ YES PASS SERIAL # _ NO FAIL L/D TYPE:_ YES PASS SERIAL # _ NO FAIL I CERTIFY THE ABOVE TESTS WERE CONDUCTED ON THIS DATE ACCORDING TO RED JACKET PUMPS FIELD TEST APPARATUS TESTING PROCEDURE AND LIMITATIONS. THE MECHANICAL LEAK DETECTOR TEST PASS / FAIL IS DETERMINED BY USING A LOW FLOW THRESHOLD TRIP RATE OF 3 GALLONS PER HOUR OR LESS AT 10 P.S.I. I ACKNOWLEDGE THAT ALL DATA COLLECTED IS TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE. TECHNICIAN: RICH PHILL SIGNATURE: DATE: 417 -12 SWRCB, January 2006 Spill Bucket Testing Report Form This form is intendedfor use by contractors performing annual testing ofUST spill containment structures. The completedform and printouts from tests (ifapplicable), should be provided to thefacility owner /operatorfor submittal to the local regulatory agency. 1. FACILITY INFORMATION Facility Name: CHEVRON I Date ofTesting: 4 -17 -12 Facility Address: 13004 STOCKDALE HWY, BAKERSFIELD CA 93314 Facility Contact: KHENG CHOA Phone: Date Local Agency Was Notified of Testing: Name ofLocal Agency Inspector (fpresent during testing): 2. TESTING CONTRACTOR INFORMATION Company Name: RICH ENVIRONMENTAL X Direct Bury Technician Conducting Test: RICH PHILLIPS X Direct Bury Credentials': CSLB Contractor X ICC Service Tech. SWRCB Tank Tester Other (Spec) Bucket Installation Type: License Number(s): 1035169 -UT Contained in Sum 3. SPELL BUCKET TESTING INFORMATION Test Method Used: X Hydrostatic Vacuum Other Test Equipment Used: VISUAL Equipment Resolution: 0 Identify Spill Bucket (By Tank I I REG 87 -FILL 2 PLUS89- FILL 3 PREM 91 -FILL 4 DIESEL -FILL Number, StoredProduct, etc.) Bucket Diameter: X Direct Bury X Direct Bury X Direct Bury X Direct BuryBucketInstallationType: Contained in Sum Contained in Sum Contained in Sum Contained in Sum Bucket Diameter: 12" 12" 12" 12" Bucket Depth: 14" 14" 14" 14" Wait time between applying vacuum/water and start oftest: 30 MIN 30 MM 30 MIN 30 MM Test Start Time (TO: 12:00 12:00 9:30 9:30 Initial Reading (Rj): 9" 9" 9" 9" Test End Time (TF): 1:00 1:00 10:30 10:30 Final Reading (RF): 9" 9" 9" 9" Test Duration (TF - TO: 1 -HOUR 1 -HOUR I -HOUR 1 -HOUR Change in Reading (RF- Rj): 0 0 0 0 Pass/Fail Threshold or Criteria: 0.00 0.00 0.00 0.00 Test Result: X Pass Fail X Pass Fail X Pass Fail X Pass Fail Comments — (include information on repairs made prior to testing, and recommendedfollow -upforfailed tests) RE TEST ON 87- 89 FILL BUCKETS AFTER CLEANING DRAIN VALVES BOTH PASSED CERTIFICATION OF TECHN19XN RESPONS ®LE FOR CONDUCTING THIS TESTING 1 hereby certify that all the information con ed in this report is true, accurate, and infull compliance with legalrequirements. Technician's Signature: Date: 4 -17 -12 State laws and regulations do not currently require testing to be performed by a qualified contractor. However, local requirements may be more stringent. I' F 011 TE21, I Tt 11 '_;ETijP IT, I VIE i:iNN I f-iiibt. El 1 iLUE .L,FC,' F I, I, 1, I-IF I oH. I F. . I.. I iBLED llfit E: I'P,1' T0(:(.',I. Uf-il'Fi I -';j id, U',) j V. I CHT 11 a, ;W11, ;-;iivjhl; r I tIE iTj LRE It I C_-Iwiki SERV I 'E N(Yf I CE Ilv-11 A DISABLED I' ItI 3166 COUNTRV I IA: CODE: TL I h IT 1 +1 A I 't V z I I I'll I F iI-V-juJ%i I c -I- I*] PORT SETT I NGr-.W! 1 1. t il l Comm BOARD, Rs -232 . SECURITV SABLED W., ARD 2, ( RS — _2 ATE 1-200 T' , ' ODD B) T I STUD I_Etkaii: 7 DATA 1:':;`-232 SECURITY DISABLED.', ..fill A 1.: 11, 1 LEAK AU Ri Ii I i-31-i WATER LED OVERFILL LIMVI`,, BLED 1-1: le I I I I." "ht::- I' Flmll L'W PRODLIC:T. I Ill IT . TElff PHIL i,HNI: T: i'1' I J1 I 1-11 J-1 i-AhTI.' R I. 1 111 1 161 Jet l I it fil fl I ) I f 1,% + I viLIMITit.). iI. 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FAILURE REPORT SITE NAME: CHEVRIN DATE: 4 -17 -12 ADDRESS: 13004 STOCKDALE HWY TECHNICIAN: RICH ILLIPS CITY: BAKERSFIELD SIGNATURE: REPAIRS: REPLACED 89 LEAK DETECTOR PARTS INSTALLED: NONE 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.