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Home My WebLink About1415 TRUXTUN AVENUE (8)MONITORING SYSTEM CERTIFICATION For Use All Jurisdictions Within the State ofCalifornia Authority Cited: Chapter 6.7, Health Safety Code; Chapter 16, Division 3, Title 23, California Code ofRegulations This form must be used to document testing and servicing ofmonitoring 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: K M n4tkiN t2elVIMI St ril,CPS /,/ Bldg. No.: Site Address: —/Y-/S- 7IYt t rt(rr-o 1/t. City: &ar_cr .i°Nt zip: Facility Contact Penton: Contact Phone No.: Make/Model of Monitoring System: Date ofTesting/Servicing: v , _.9R_ B. Inventory of Equipment Tested/Certified Check the anuroorlate hones to Ingrate same enulnment limu-. ftrilwmiroA- Tank ID: 77 7= Tank ID: 0 In -Tank Gauging Probe. Model: In -Tank GaugingProbe. Model: 1* Annular Space or Vault Sensor. Model: W Annular Space orVault Sensor. Model: Al Piping Sump /Trench Sensor(s). Model: S't4.hiG.Sehsor Piping Sump /Trench Sensor(s). Model: Fill Sump Sensor(s). Model: Fill Sump Sensor(s). Model: Mechanical Line Leak Detector. yModel: / Mechanical Line Leak Detector. Model: Electronic Line Leak Detector. Model: O Electronic Line Leak Detector. Model: Tank Overfill/ High -Level Sensor. Model: Tank Overfill / High -Level Sensor. Model: Cl Other (=ify equipment type and model in Section E on Page 2). Other equipment type and model in Section E on Page 2). Tank ID• Tank ID: In -Tank Gauging Probe. Model: O In -Tank Gauging Probe Model: Annular Space or Vault Sensor. Model: O Annular Space or Vault Sensor. Model: Cl Piping Sump /Trench Sensor(s). Model: O Piping Sump /Trench Sensor(s). Model: Fill Sump Sensor(s). Model: Fill Sump Sensor(s). Model: O Mechanical Line Leak Detector. Model: O Mechanical Line Leak Detector. Model: Electronic Line Leak Detector. Model: Electronic Line Leak Detector. Model: O Tank Overfill /High -Level Sensor. Model: O Tank Overfill /High -Level Sensor. Model: Other (specify equipment type and model in Section E on Page 2). Other(s uIE=t qpE and model in Section E on Pa e 2 . Dispenser ID: Dispenser ID: Dispenser Containment Sensor(s). Model: O Dispenser Containment Sensor(s). Model: Shear Valve(s). O Shear Valve(s). U Dispenser Containment Float(s) andChains . O Dispenser Containment Floats and Chains . Dispenser ID: Dispenser ED: O Dispenser Containment Sensor(s). Model: O Dispenser Containment Sensor(s). Model: O Shear Valve(s). O Shear Valve(s). O Dispenser Containment Float(s) and Chain(s). Dispenser Containment Floats and Chain(s). Dispenser ID: Dispenser ID: O Dispenser Containment Sensor(s). Model: Dispenser Containment Sensor(s). Model: Shear Valve(s). Shear Valve(s). UDispenser Containment Float(s) and Chain(s). Dispenser Containment Floats and Chain(s). If the facility contains morn tanks ordispensers, copy this form. Include information for every tank and dispenser at the facility. C. Certification . I certify Mat 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 ofmonitoring eulpment. For any equipment capable of generating such reports, I have also attached a copy ofthe rt; (check aAlhatapply): System set-up Ili Alarm history report Technician Name (print) - 1`264.LC l(f 64Vet-j Signature: Certification No.: /¢ 25,212— License. No.: Testing Company Name: _ - Lci j a s'il'' Phone No.: ( 661 ) 32 793 r/I Site Address: J yIS` Zl'7,t.iY7`4w iw, Date ofTesting/Servicing. Lv_j pVez Page 1 of 3 03101 Monitoring System Certification. Yes No* Is the audible alarm operational? 0 Yes O No* Is the visual alarm operational? Yes No* Were all sensors visually inspected, functionally tested, and confirmed operational? 61 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) CO N/A operational? Yes L3 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) 0 Sump/Trench Sensors; O Dispenser Containment Sensors. Did you confirm positive shut -down due to leaks pd sensor failure/disconnection? ® Yes; No. Yes No* For tank systems that utilize the monitoring system as the primary tank overfill warning device C.e. no 01 N/A mechanical overfill prevention valve is installed), is the overfill wanting alarm visible and audible at the tank fill point (s) and operating properly? Ifso, at what percent of tank capacity does the alarm trigger? % 0 Yes* 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 I., below. Yes* 0 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 settings? Attach set u re if applicable Yes No* Is all monitorin ui ment o rational manufacturer's s cations? In Section E below, describe how and when these deficiencies were or will be corrected. E. Comments: T 7`G yb}24 S!L4me ,5e,7sa,r tidal rei014-cea' 726e n2 n=h e2iai Wet r -&/J 04 W&JLer Se rare' LZ a/- -4 Wei, -- ih QLa 1yi oh ',' S'i'te Liar 6 rr'i'i'/ye ,C,4 41h S-e ale L -2 a lP,edcrr r n have Page 2 or3 03/01 e i 1 I r F. 'In -Tank Gauging / SIR Equipment: ® Check this box iftank gauging is used only for inventory control. O 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. Comnlete 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? 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 the Section H, below, describe how and when these deficiencies were or will be corrected. G. Line Leak Detectors (LLD): O Check this box if LLDs are not installed. mmnlete the fnllawiner rhPA-11ctr es No* For equipment start-up or annual equipment certification, was a leak simulated to verify LLD performance? 13 N/A Check all that apply) Simulated leak rate: 3 g.p h.; 0.1 g.p.h ; 0.2 g.p.h. es No* Were all L.L.Ds 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 Yes1c, O No* For electronic LLDs, does the turbine automatically shut off if 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 0 N/A or disconnected? O Yes No* For electronic LLDs, does the turbine automatically shut offif any portion of the monitoring system malfunctions 0 N/A or fails a test? Yes O No* For electronic LLDs, have all accessible wiring connections been visually inspected? 0 N/A Yes W 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 correcte(L H. Comments: The merhai,xl /Ihe /east tecz!2r Cac'-&Z yto7,-he . Llie Yo f 61ke- r Sf rc, j 'ti rir th'. W)i tb HA shear lea. /lie pyc .S ,e/ohlkrJ Vp-Iye. Page 3 of 3 03ro1 Monitoring System Certification UST Ajonitoring Site Plan Site Address: nt x '' at; , , ...... * , , * * , , * , * * * * , , , * * , * , , I ....................... I ......................................... I. .... I ......................... I . I ........... I ........................ .............. I ............ S ............ I ........................ Gar- 'a9-e. .................. I ............... I ... :**''—'—'*—** 0:: ........ 7 ... E, ......... I ..................... ..................t- %s2........ 1. Fill ............. I.. I ......... I . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I . . I . . . . . . . . I . . . I . . . . . . . . . . . . . . . I . . . . . . . . . . . . . . . . . . . I . . . . . . . . . . Date map was drawm.] Qj 7 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. Page !L of 1 05/00