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Home My WebLink About1415 TRUXTUN AVENUE (7)rz l Appendix VI Copies of Monitoring System Certification form and UST Monitoring Plot Plan available at htti): / /www.waterboards.ca.gov.) 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 of Regulations 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: County of Kern Bldg. No.: Site Address: 1415 Truxtun Ave. City: Bakersfield Zip: Facility Contact Person: Tim Haub Contact Phone No.: U Make /Model of Monitoring System: Veeder Root TLS 350 Date of Testing /Servicing: 2 / 24 / 2012 B. Inventory of Equipment Tested /Certified Check the appropriate boxes to indicate specific equipment ins ected /serviced: Tank ID: DSL Tank ID: X In -Tank Gauging Probe. Model: Veeder Root 846390 D In -Tank Gauging Probe. Model: X Annular Space or Vault Sensor. Model: Veeder Root 794380 -301 Annular Space or Vault Sensor. Model: X Piping Sump / Trench Sensor(s). Model: VR 794380 -208, 351 2 Piping Sump / Trench Sensor(s). Model: Fill Sump Sensor(s). Model: Fill Sump Sensor(s). Model: X Mechanical Line Leak Detector. Model: VMI LD2000 Mechanical Line Leak Detector. Model: Electronic Line Leak Detector. Model: Veeder Root 849490 Electronic Line Leak Detector. Model: _ X Tank Overfill / High -Level Sensor. Model: OPW 61 SO D Tank Overfill / High -Level Sensor. Model: L Other specify equipment t e and model in Section E on Page 2). Other (specify equipment type and model in Section E on Page 2). TanklD: TanklD: E In -Tank Gauging Probe. Model: In -Tank Gauging Probe. Model: C Annular Space or Vault Sensor. Model: Annular Space or Vault Sensor. Model: E Piping Sump / Trench Sensor(s). Model: Piping Sump / Trench Sensor(s). Model: L Fill Sump Sensor(s). Model: Fill Sump Sensor(s). Model: L Mechanical Line Leak Detector. Model: Li Mechanical Line Leak Detector. Model: Electronic Line Leak Detector. Model: Electronic Line Leak Detector. Model: 2 Tank Overfill / High -Level Sensor. Model: Tank Overfill / High -Level Sensor. Model: i Other(specify equipment t e and model in Section E on Page 2). Other(specify equipment t e and model in Section E on Pa Dispenser ID: _ Dispenser ID: X Dispenser Containment Sensor(s). Model: X Dispenser Containment Sensor(s). Model: BEI -406 X Shear Valve(s). X Shear Valve(s). Dispenser Containment Floats and Chains . Dispenser Containment Floats and Chain(s). Dispenser ID: DispenserID: X Dispenser Containment Sensor(s). Model: X Dispenser Containment Sensor(s). Model: BEI -406 X Shear Valve(s). X Shear Valve(s). Dis enser Containment Float(sl and Chain(s). Dis enser Containment Floats and Chains . Dispenser ID: Dispenser lD: X Dispenser Containment Sensor(s). Model: Dispenser Containment Sensor(s). Model: X Shear Valve(s). Shear Valve(s). I Dispenser Containment Floats and Chains L Dispenser Containment Floats 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 o enerating such reports, I have also attached a copy of the report; (check all that apply): 11 System set -up Alarm history report Technician Name (print): Josh Simmons Signature: Certification No.: 5242369 -UT License. No.: 481053 Testing Company Name: Kern County Construction, Inc Phone No.:( 661 1 634 -9950 Testing Company Address: PO Box 6096, Bakersfield, CA 93386 Date of Testing /Servicing: 2 / 24 / 2012 Monitoring System Certification Page 1 of 4 12107 2/21/07 D. Results of Testing /Servicing Software Version Installed: Complete the following checklist: X Yes 7 No* Is the audible alarm operational? X Yes u No* Is the visual alarm operational? Yes X No* Were all sensors visually inspected, functionally tested, and confirmed operational? X Yes f l No* Were all sensors installed at lowest point of secondary containment and positioned so that other equipment will not interfere with their roper operation? X Yes E, No* If alarms are relayed to a remote monitoring station, is all communications equipment (e.g. modem) operational? N/A X Yes a No* For pressurized piping systems, does the turbine automatically shut down if the piping secondary containment monitoring system E, N/A detects a leak, fails to operate, or is electrically disconnected? If yes: which sensors initiate positive shut -down? (Check all that apply) X Sump/Trench Sensors; ii Dispenser Containment Sensors. Did you confirm positive shut -down due to leaks and sensor failure /disconnection? X Yes; No. Yes F1 No* For tank systems that utilize the monitoring system as the primary tank overfill warning device (i.e. no mechanical overfill prevention X N/A 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* X 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. X Yes* E No Was liquid found inside any secondary containment systems designed as dry systems? (Check all that apply) _. Product; u Water. If es, describe causes in Section E, below. X Yes G No* Was monitoring system set -up reviewed to ensure proper settings? Attach set up reports, if applicable X Yes C! 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: STP Sumo sensor didn't function when first tested. Fire Department wants sensor repaired. Monitoring System Certification Page 2 of 4 12107 2/21/07 Monitoring System Certification Page 2 of 4 12107 2/21/07 F. In -Tank Gauging / SIR Equipment: 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: X Yes Ll No* Has all input wiring been inspected for proper entry and termination, including testing for ground faults? X Yes G No* Were all tank gauging probes visually inspected for damage and residue buildup? X Yes L-1 No* Was accuracy of system product level readings tested? X Yes No* Was accuracy of system water level readings tested? X Yes n No* Were all probes reinstalled properly? X Yes L 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): Check this box if LLDs are not installed. Complete the following checklist: X Yes L No* For equipment start-up or annual equipment certification, was a leak simulated to verify LLD performance? (Check all C N/A that apply) Simulated leak rate: X 3 g.p.h.; -, 0.1 g.p.h ; = 0.2 g.p.h. X Yes No* Were all LLDs confirmed operational and accurate within regulatory requirements? X Yes I_I No* Was the testing apparatus properly calibrated? X Yes l No* For mechanical LLDs, does the LLD restrict product flow if it detects a leak? U N/A ii Yes No* For electronic LLDs, does the turbine automatically shut off if the LLD detects a leak? X N/A Yes No* For electronic LLDs, does the turbine automatically shut off if any portion of the monitoring system is disabled or X N/A disconnected? 2 Yes 11 No* For electronic LLDs, does the turbine automatically shut off if any portion of the monitoring system malfunctions or X N/A fails a test? L Yes No* For electronic LLDs, have all accessible wiring connections been visually inspected? X N/A X Yes n 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: Monitoring System Certification Page 3 of 4 12/07 4 2/21/07 Monitoring System Certification UST Monitoring Site Plan Site Address: % 7 U Xtl% h A e Date map was drawn: _Z-_/_Z —q/-L7—. Instructions If you already have a diagram that shows all required information, you may include it, rather than this page, with your Monitoring System Certification. On your site plan, show the general layout of tanks and piping. Clearly identify locations of the following equipment, if installed: monitoring system control panels; sensors monitoring tank annular spaces, sumps, dispenser pans, spill containers, or other secondary containment areas; mechanical or electronic line leak detectors; and in -tank liquid level probes (if used for leak detection). In the space provided, note the date this Site Plan was prepared. Monitoring System Certification Page 4 of 4 12107 5 2/21/07 SWRCB, January 2006 Spill Bucket Testing Report Form Thisform is intendedfbr use by contractors performing annual testing of UST spill containment structures. The completed form and printoutsfrom tests (ifapplicable), should be provided to thefacility owner /operatorfor submittal to the local regulatory agency. 1. FACILITY INFORMATION Facility Name: County of Kern I Date of Testing: 2 -24 -12 Facility Address: 1415 Truxtun Ave. Facility Contact: Tim Haub Phone: Date Local Agency Was Notified of Testing : 2 -22 -12 Name of Local Agency Inspector (ifpresent during testing): Ernie Medina 2. TESTING CONTRACTOR INFORMATION Company Name: Kern County Construction, Inc. PO Box 6096, Bakersfield, CA 93386 Technician Conducting Test: Josh Simmons Credentials': X CSLB Contractor X ]CC Service Tech. SWRCB Tank Tester Other (Specify) License Number(s): 481053 5242369 -UT 3. SPILL BUCKET TESTING INFORMATION Test Method Used: XHydrostatic Vacuum Other Test Equipment Used: Visual Equipment Resolution: 0.0" Identify Spill Bucket (Av Tank Number, Stored Product, etc.) 1 DSL 2 3 4 Bucket Installation Type: X Direct Bury Contained in Sump Direct Bury Contained in Sum Direct Bury Contained in Sump Direct Bury Contained in Sum Bucket Diameter: H,, Bucket Depth: 15" Wait time between applying vacuum /water and start of test: 15 Min. Test Start Time (T,): 9:30 Initial Reading (Rj): 7" Test End Time (TI:): 10:30 Final Reading (Rr): 5" Test Duration (TF — Ti): 1 Hr. Change in Reading (RF - Ri): 2.0" Pass /Fail Threshold or Criteria: 0.0" Test Result: Pass X Fail Pass Fail Pass Fail Pass Fail Comments — (include information on repairs made prior to testing, and recommendedfollow -uup forfailed tests) Bucket failed needs to be replaced CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING I hereby certify that all the informntior Wined in Ibis report is true, accurate, and in full compliance with legal requirements. Technician's Signature: Date: ; -7 —Z —1 0 State laws and regulations do not currently require testing to be performed by a qualified contractor. However, local requirements may be more stringent. 41NO-L TES I PEPI('DIC TD---it FE,!-','r F"IL Hfdfd TEST ERA I hJ Pd PH%' TEST 1*61AK TEST N,.'YFIF,`: :_TF' CNI: TS"T SIPHC"N THNK Dir-11"IETEE' FPC'IFILE I 1''L FULL I I:-: FLHT 2`1=: 4.1--1 111. 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