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HomeMy WebLinkAbout2011-12-06 FMCbeishire environmental services, inc. 25971 Towne Centre Drive, Foothill Ranch, CA 92610 Tel: (949) 460 -5200 Fax: (949) 460 -5210 TRANSMITTAL Date: 1/3/2012 To: UST Program Bakersfield Fire Dept. 1500 Truxtun Ave Bakersfield, CA 93301 From: Shawna Chambers Sent Via: UPS Ground Tracking #: 1ZF834R60397257089 Re: Monitoring System Certification RALPHS# 384 2501 Haley St. Bakersfield, CA 93305 The following test report(s) are included: Monitoring System Certification performed on 12/6/2011. Comments: F2; / Please do not hesitate to call me at (949) 460 -5200 if you have any questions or concerns regarding this work. rown UPS Internet Shipping: Shipment Label UPS Internet Shipping: View /Print Label 1. Ensure there are no other shipping or tracking labels attached to your package. Select the Print button on the print dialog box that appears. Note: If your browser does not support this function select Print from the File menu to print the label. 2. 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Customers with a Daily Pickup Your driver will pickup your shipment(s) as usual. FOLD HERE w O N' Ln m w w ... M ,+• 0 01 N OMO m nwp F4 —I 04 I z [.zy. 77 OV. WN0 0 Q 0 0 M 0 00 N hh i V z vJ o o a a z Gi L '• O ti ii• I i Page 1 of 1 https: / /www.ups.com/uis/ create ?ActionOriginPair = default PrintWindowPage &key= label... 1/3/2012 Appendix VI Copies of Monitoring System Certification form and UST Monitoring Plot Plan available at http: / /www.waterboat,ds.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: Foods Co #384 Bldg. No.: Site Address: _2501 Haley St. _ City: Bakersfield Zip: 93305 Facility Contact Person: Make/Model of Monitoring System: Veeder -Root TLS -35OR Contact Phone No.: ( Date of Testing /Servicing: __12/6/2011 B. Inventory of Equipment TestedrCertified Check the appropriate boxes to indicate specific equipment Inspected /serviced: Tank ID: Unleaded Tank ID: Premium I i In -Tank Gauging Probe. Model: 846390 -110 In -Tank Gauging Probe. Model: 6:396 =i10- Vj Annular Space or Vault Sensor. Model: 794380 -303 V, Annular Space or Vault Sensor. Model: r with Uieset Piping Sump / Trench Sensor(s). Model: 794360 - 3Ln d Piping Sump / Trench Sensor(s). Model: I`di CI Fill Sump Sensor(s). Model: 794380 -3-r Fill Sump Sensor(s). Model: Mechanical Line Leak Detector. Model: I Mechanical Line Leak Detector. Model: di Electronic Line Leak Detector. Model: PLLD Idi Electronic Line Leak Detector'. Model: PLLD jdj Tank Overfill ! High -Level Sensor. Model: 846390 -11fI flank Overfill / High -Level Sensor. Model: 846390 -110 I Other (specify a ui ment t and model in Section E on 1 1 Other s ecif a ui ent t and model in Section E on Page 2 . Tank ID: Diesel Tank ID: LI In -Tank Gauging Probe. Model: 6390-110 In -Tank Gauging Probe. Model: V1 Annular Space or Vault Sensor. Model: 794380-303 Annular Space or Vault Sensor. Model: I/I Piping Sump / Trench Sensor(s). FBI Model: 794380 -323 Piping Sump / Trench Sensor(s). Model: Fill Sump Sensor(s). Model: 794380 -323 Fill Sump Sensor(s). Model: L _ Mechanical Line Leak Detector. Model: Mechanical Line Leak Detector. Model: Imo; Electronic Line Leak Detector. Model: PLLD Electronic Lune Leak Detector. Model: VI Tank Overfill / High -Level Sensor. Model: 846390 -110 I Tank Overfill / High-Level Sensor. Model: _ Others (specify a ur nent t and model In Section E on Pa e 2 . l Other (s ec' a ui ment t and model in Section E on Page 2L Dispenser ID: 1 / 2 Dispenser ID: 3/4 Vj Dispenser Containment Sensor(s). Model: 794380 -323 Vi Dispenser Containment Sensorls). Model: 794380 -323 4/; Shear Valve(s). j j Shear Valve(s). j Dispenser Containment Floats and Chains . Dis enser Containment Boats and Chain(s). Dispenser ID: 5 / 6 Dispenser ID: 7/8 Dispenser Containment Sensor(s). Model: 794380 -323 Ivp; Dispenser Containment Sensor(s). Model: 794380 -323 V. Shear Valve(s). Shear Valve(s). Dispenser Containment Roat(s) and Chain(s). Dispenser Containment Float(s) and Chain(s). Dispenser ID: 9 / 10 Dispenser ID: 11/12 - 13/14 Vi Dispenser Containment Sensor(s). Model: 794380 -323 A/j Dispenser Containment Sensor(s). Model: 794380 -323 V; Shear Valve(s). 011 Shear Valve(s). Dis enser Containment Roat(s ) and Chains 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 of generating such reports, I have also attached a copy of the report; (check alf that apply): /! System set -up !./'Alarm history report Technician Name (print): Hensley Barbour Signature: Certification No.: A20490 License: No.: 808313 Testing Company Name: Belshire Environmental Services, Inc. Phone No.:( 949 ) 460 -5200 Testing Company Address: 25971 Towne Centre Dr. , Foothill Ranch, CA 92610 Date of Testing /Servicing: 1216/2011 Monitoring System Certification Page 1 of 4 12/07 2/21/07 D. Results of Testing /Servicing Software Version Installed: 330.01 Complete the following checklist: Yes f j No' Is the audible alami operational? v Yes I i No' Is the visual alarm operational? dlYes I No' Were all sensors visually inspected, functionally tested, and confirmed operational? hjlYes I No' Were all sensors installed at lowest point of secondary containment and positioned so that other equipment will not interfere with their proper operation? VIYes No' If alamns are relayed to a remote monitoring station, is all communications equipment (e.g. modem) operational? N/A IYes I i No' For pressurized piping systems, does the turbine automatically shut down f the piping secondary containment monitoring system N/A riAtects a leak, fails to operate.. or is electrically disconnected? If yes: which sensor initiate positive shut -down? (Check all that apply) VISump/Trench Sensor; VI. Dispenser Containment Sensors. Did you confirm positive shut -down due to leaks and sensor failure/disconnection? ,dlYes; I INo. jyes I i No" N/A For tank systems that utilize the monitoring system as the primary tank overfill warning device (i.e. no mechanical overfill prevention is installed), is the at the tank fill and operating If so, atvalveoverfillwarningalarmvisibleandaudiblepoint(s) properly? what percent of tank capacity does the alarrn trigger? 90 % jVjYes' j 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. IYes' WI No Was liquid found inside any secondary containment systems designed as dry systems? (Check all that apply }; ,Product ; ; _ Water. If es describe causes in Section E below. Yes j No' Was monitoring system set -up reviewed to ensure proper settings? Attach set up reports, if applicable r Yes j No' I 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: Replaced 91 STP sump sensor. 794380 -323 Vent Box: 794380 -323 and 794380 -304 794380 -304 Brine sensors in Turbine sump, Fil sump and UDC's. Monitoring System Certification Page 2 of 4 12/07 2 2/'21/07 F. In -Tank Gauging/ SIR Equipment: I Check this box if tank gauging is used only for inventory control. I I 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. Comolete the followina checklist: I Yes I No* Has all Input wiring been inspected for proper entry and termination, including testing for ground faults? Yes j ; No* Were all tank gauging probes visually inspected for damage and residue buildup? Yes j I No* Was accuracy of system product level readings tested? Yes j I No* Was accuracy of system water level readings tested? Yes j ) No' Were all probes reinstalled property? 41 Yes 1. 1 No* Were all items on the equipment manufacturer's maintenance checklist completed? in the section m, nelow, oescrioe now ana wnen tnese aenciencies were or will oe correctea. G. Line Leak Detectors (LLD): I I Check this box if LLDs are not installed. C_mmnlata tha fnllnwinn chnckiiSt- Yes 1 No* For equipment start -up or annual equipment certification, was a leak simulated to verify LLD performance? (Check all N/A that apply) Simulated leak rate: 11,4 3 g.p.h.; I 1,0.1 g.p.h ; i ! 0.2 g.p.h. I Yes j I No* Were all LLDs confirmed operational and accurate within regulatory requirements? Yes I No* Was the testing apparatus properly calibrated? I Yes 1 1 No* For mechanical LLDs, does the LLD restrict product flow if it detects a leak? V1 N/A Yes I No* For electronic LLDs, does the turbine automatically shut off if the LLD detects a leak? l.. NIA Yes 1 l No* For electronic LLDs, does the turbine automatically shut off if any portion of the monitoring system is disabled or NIA disconnected? 41 Yes No* For electronic LLDs, does the turbine automatically shut off if any portion of the monitoring system malfunctions or 1 N/A fails a test? Yes I No* For electronic LLDs, have all accessible wiring connections been visually inspected? N/A idl Yes I 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 3 21/21/07 Monitoring System Certification Form: Addendum for Vacuum /Pressure Interstitial Sensors I. Results of Vacuum /Pressure Monitoring Equipment Testing LG 163 -1, Enc. If 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: Veeder -Root Model: System'Type: Pressure; ® Vacuum Sensor ID X 16 Component(s) Monitored by this Sensor: 87 Product S9 Sensor Functionality Test Result: ® Pass; Fail Interstitial Communication Test Result: ® Pass; Fail Component(s) Monitored by this Sensor: 91 Vapor S10 Sensor Functionality Test Result: ® Pass; Fail Interstitial Communication Test Result: ® Pass; Q Fail Component(s) Monitored by this Sensor: 87 Vent S11 Sensor Functionality Test Result: ® Pass; Fail Interstitial Communication Test Result: ® Pass; Fail Component(s) Monitored by this Sensor: 91 Product S12 Sensor Functionality Test Result: ® Pass; Fail Interstitial Communication Test Result: ® Pass; Fail Component(s) Monitored by this Sensor: 91 Vent S13 Sensor Functionality Pest Result: ®Pass; Fail Interstitial Communication Test Result: ®Pass; 7 Fail Component(s) Monitored by this Sensor: Diesel Product S14 Sensor Functionality Test Result: ® Pass; Fail Interstitial Communication Test Result: ® Pass; Fail Component(s) Monitored by this Sensor: Diesel Vent S17 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 How was interstitial communication verified? Leak Introduced at Far End of Interstitial Space;' Gauge; Visual Inspection; Other (Describe in Sec. J, beloi) Vacuum was restored to operating levels in all interstitial spaces: ® Yes No (/fno, describe in Sec. J, below) J. Comments: Page 1 of I If the sensor successfully detects a simulated vacuum /pressure leak introduced in the interstitial space at the furthest point from the sensor, vacuum /pressure has been demonstrated to be communicating throughout the interstice. begshiore environmental services, inc. 25971 Towne Centre Drive, Foothill Ranch, CA92610 Leak Detector Test Form trotoo1' Moughl to you by URlahae Ep.-Onn ft} I aR viCnP, InG 5 Location Name: Foods Co #384 Date: 12/6/2011 Address: 2501 Haley St. Agency: Premium City, State Bakersfield , CA Inspector: Veeder Root Line Number: 1 2 3 4 Product: Unleaded Premium Diesel Manufacturer: Veeder Root Veeder Root Veeder Root Model #: PLLD PLLD PLLD Full Operating Pressure (psi): 28 28 28 Line Bleed Back (ml): N/A N/A N/A Trip Time (sec): N/A N/A N/A Metering Pressure (psi): N/A N/A N/A F/E Holding Pressure (psi) N/A N/A N/A Test Leak Rate (gph) 3.0 3.0 3.0 Pass /Fall Pass Pass Pass Comments: Technician Name Technician Signature rev. 08/26/2011 Hensley Barbour SWRCB, January 2006 Spill Bucket Testing Report Form Thisform is intended.Jor use by contractors performing annual testing of UST spill containment structures. The completedfarm and printouts from tests (ifapplicable), should be provided to thefacility otivner /operatorfor submittal to the local regulatory agency. 1. FACILITY INFORMATION Facility Name: Ralphs 384 Date of Testing: 12/6/2011 Facility Address: 2501 Haley St., Bakersfield, CA 93305 Facility Contact: I Phone: Date Local Agency Was Notified of Testing : 1112212011 Name of Local Agency Inspector (rfpresent during testing): 2. TESTING CONTRACTOR INFORMATION Company Name: Technician Conducting Test: Hensley Barbour Credentials: CSL13 Contractor ICC Service Tech. SWRCB Tank Tester Other (Specify) License Number(s): 808313 3. SPILL BUCKET TESTING INFORMATION Test Method Used: Hydrostatic Vacuum Other (Visual) Test Equipment Used: Visual Test Equipment Resolution: Identify Spill Bucket (lay Tank Number, Stored Product, etc. 1 87 Fill 2 87 Fill 3 91 Fill 4 Diesel Fill Bucket Installation Type: Direct Bury Contained in Sump Direct Bury Contained in Sump Direct Bury Contained in Sump Direct Bury Contained in Sum Bucket Diameter: 12" 12" 12" 12" Bucket Depth: 12" 12" 12" 12" Wait time between applying vacuum /water and start of test: 10 min 10 min 10 min 10 min Test Start Time (Ti): 10:15 AM 10:15 AM 10:15 AM 10:15 AM Initial Reading (RI): 8" 8" 8" 8" Test End Time (TF): 11:15 AM 11:15 AM 11:15 AM 11:15 AM Final Reading (RF): 8" 8" 8" 8" Test Duration (TF —T,): 60 min 60 min 60 min 60 min Change in Reading (RF- Ri): 0" 0" 0" 0" Pass /Fail Threshold or Criteria: 0" 0" 0" 0" Test Result: Pass Fail Pass Fail Pass Fail Pass Fail Comments — (include information on,repairs made prior to testing, and recommendedfollow -up for./ailed tests) Test Water: Placed in existing drum Placed in drurn provided by Belshire Other (describe below) Test water was left on -site. CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING hereby certify that all the information contained in this report is true, accurate, and infull compliance with legal requirements. Technician's Signature: I Date: 12/6/2011 State laws and regulations do not currently require testing to be performed by a qualified contractor. However, local requirements may be more stringent. SWRCB, January 2006 Spill Bucket 'besting Report Form Thisform is intendedfor use by contractors peiforining annual testing of UST spill containment structures. The completedfibrin and printoutsfrom tests (inapplicable), should be provided to thefacility owner /operatorfor submittal to the local regulatory agency. 1. FACILITY INFORMATION Facility Name: Ralphs 384 1 Date ofTesting: 12/612011 Facility Address: - 2501 Haley St., Bakersfield, CA 93305 Facility Contact: I Phone: Date Local Agency Was Notified of Testing : 11/22/2011 Name of Local Agency Inspector (ifpresent during testing): 2. TESTING CONTRACTOR INFORMATION Company Name: Technician Conducting Test: Hensley Barbour Credentials: CSLB Contractor iCC Service Tech. SWRCB Tank Tester Other (Speciifv) License Number(s): 808313 3. SPILL BUCKET TESTING INFORMATION Test Method Used: Hydrostatic 0 Vacuum Other (Visual) Test Equipment Used: Visual Test Equipment Resolution: Identify Spill Bucket (By Tank Number, Stored Product, etc. 1 87 Vapor 2 87 Vapor 3 91 Vapor 4 Bucket Installation Type: Direct Bury Contained in Sump Direct Bury Contained in Sump Direct Bury Contained in Sump Direct Bury Contained in Sum Bucket Diameter: 12" 12" 12" Bucket Depth: 12" 12" 12" Wait time between applying vacuum /water and start of test: 10 min 10 min 10 min Test Start Time (Ti): 10:15 AM 10:15 AM 10:15 AM Initial Reading (lt): 8" 8" 8" Test End Time (TF): 11:15 AM 11:15 AM 11:15 AM Final Reading (RF): 8" 8" 8" Test Duration (TF — Ti): 60 min 60 min 60 min Change in Reading (RF- Ri): 0" 0" 0" Pass /Fail Threshold or Criteria: 01 0" 0" Test Result: Pass. Fail N Pass 0 Fail Pass Fail Pass Fail Comments — (include information on repairs made prior to testing, and recommendedfolloly -upforfailed tests) Test Water: Placed in existing drum Placed in drum provided by Belshire Other (describe below) Test water was left on -site. CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING hereby certify that all the information contained in this report is true, accurate, and iii full compliance wish legal requirements. Technician's Signature: ,- y,i Date: 12/6/2011 State laws and regulations do not currency require testing to be performed by a qualified contractor. However, local requirements may be more stringent.