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HomeMy WebLinkAbout2601 WHITE LANE (5)Pzs s MONITORING SYSTEM CERTIFICATION to 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_renort must be prenaMd for each monitoring sySem 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 ofthis fort to the local agency regulating UST systems within 30 days oftest date. A. General Information Facility Name: HARRY'S MARKET #2 Bldg. No.: Site Address: 2601 WHITE LN City: BAKERSFIELD Zip: Facility Contact Person: YOGI Contact Phone No.: ( ) Make /Model ofMonitoring System: TLS 350 Date ofTesting/Servicing: 11/17/2011 B. Inventory of Equipment Tested/Certified Check the annronriate boxes to indicate snecifle eauipment insnected/serviced: Tank ID: UNL871SPLIT Tank ID: PREM911SPLIT 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: 208 Fill Sump Sensor(s). Model: 208 Fill Sump Sensor(s). Model: 208 Mechanical Line Leak Detector. Model: RED JACKET Mechanical Line Leak Detector. Model: RED JACKET 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). Tank ID: Tank ID: In -Tank Gauging Probe. Model: In -Tank Gauging Probe. Model: Annular Space or Vault Sensor. Model: Annular Space or Vault Sensor. Model: Piping Sump / Trench Seasor(s). Model: Piping Sump / Trench Sensor(s). Model: 0 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: 1 -2 Dispenser ID: 3-4 Dispenser Containment Sensor(s), Model: 208 Dispenser Containment Sensor(s). Model: 208 Shear Valve(s). Shear Valve(s). Dispenser Containment Floats) and Chain(s). Dispenser Containment Float(s) and Chain(s). Dispenser ID: 6.6 Dispenser ID: 7-8 DispenserContainment Sensor(s). Model: 208 Dispenser Containment Sensor(s). Model: 208 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 Ftoat(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 inspectediserviced 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 ofgenerating such reports, I have also attached a copy of the report; (check all that apply): ® System set -up ® Alarm history report Technician Name (print): RICHARD MASON Signature: f. Certification No.: 836880 / 5297857 -UT License. No.: —Cel D40 809850 Testing Company Name: RICH ENVIRONMENTAL Phone No.: (661) 392 -8687 Testing Company Address: 5643 BROOKS CT. BAKERSFIELD, CA 93308 Date of Testing/Servicing: 11117/2011 Page 1 of 5 UN -036 —114 www.unidoes.org Rev. 01117/08 Monitoring System Certification 1 D. Results of Testing/Servicing Software Version Installed Complete the following checklist: 44a% r 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 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/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? 0 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* 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. Yes* No Was liquid found inside any secondary containment systems designed as dry systems? (Check all that apply) Product; Water. Ifyes, 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* 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: Page 2 of 5 UN -036 — 2/4 www.unidomorg 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 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: Yes No* Has all input wiring been inspected for proper entry and termination, including testing for ground faults? 13 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 1 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): Complete the following checklist: 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 ifit detects a leak? N/A Yes No* For electronic LLDs, does the turbine automatically shut off if the LLD detects a Ieak? 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 ofthe 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 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. H. Comments: UN-M — 3/4 Page 3 of 5 www.unidocs.org Rev. 01/17/08 Monitoring System Certification Form: Addendum for Vacuum/Pressure Interstitial Sensors ' ` (all I. Results of Vacuum/Pressure Monitoring Equipment Testing 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 oftest date. Manufacturer: NONE Model: System Type: Pressure; ® Vacuum Sensor ID 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 Component(s) Monitored by this Sensor: Sensor Functionality Test Result: Pass; Fail Interstitial Communication Test Result: Pass; Fail Components) 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 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, below) Was vacuum/pressure restored to operating levels in all interstitial spaces? Yes No (Ifno, describe in Sec. J, below) J. Comments: NONE OF THESE SENSORS ARE PRESENT AT THIS SITE. Page 4 of 5 Ifthe sensor successfully detects a simulated vacuum/pressure leak introduced in the interstitial space at the furthest point from thesensor, vacuum/pressure has been demonstrated to be communicating throughout the interstice. UN -036A - 1/1 www.unidocs.org Rev. 01/26/06 Moniwring System Ca fication UST Monitoring; Site Site Address: qLtjOz% na i L. J: ------- r - - - - - - w - _ - r - . -_ _ _ - - _ L _ _ . _ - . - . . _ - • r - If you already have a diagram that shows all required information, you may include it, rather than this page, with yourMonitoringSystemCerti$c idon. On your site plan, show the general layout oftanks and piping. Clearly idetr* locations ofthe following equipment, if installed: monitoring systft control panels; sensors monitoring tank annularspaces, sumps, dispenserpans, Viill containers, or other secondary couiainment areas; mechanical or electronic line leak detectors; and ih-tank liquid level probes (ifused for leak detection). Iathe space provided, note the date this Site Planwasprepared. Page 57 of C— 05100 44W.-S SWRCB, January 2006% Spill Bucket Testing Report Form This form is intendedfor use by contractors performing annual testing of UST spill containment structures. The completedform and printoutsfrom tests (rfapplicable), should beprovided to thefacility owner /operatorfor submittal to the local regulatory agency. 1. FACILITY INFORMATION Facility Name: HARRY'S MARKET #2 Date of Testing: 11/17/11 Facility Address: 2601 WHITE LANE, BAKERSFIELD Facility Contact: YOGI Phone. Date Local Agency Was Notified of Testing: Name of Local Agency Inspector (tfpresent during testing): ERNIE MADENA 2. TESTING CONTRACTOR INFORMATION Company Name: RICH ENVIRONMENTAL Technician Conducting Test: RICHARD MASON Credentials': 0 CSLB Contractor X ]CC Service Tech. 0 SWRCB Tank Tester 0 Other (Spec) License Number(s): 5297857 -UT 3. SPILL BUCKET TESTING INFORMATION TestMethod Used: XHydrostatic d Vacuum Other Test Equipment Used: VISUAL I Equipment Resolution: 0 Identify Spill Bucket (By Tank 1 REG 87 -FILL 2 PREM 91 -FILL 3 4 Number, StoredProduct, etc. Bucket Installation Type: 0 Direct Bury 0 Direct Bury 0 Direct Bury 0 Direct Bury Bucket Depth: X Contained in Sump X Contained in Sump Contained in Sump 0 Contained in Sum Bucket Diameter. i2" 12" Bucket Depth: 14" 14" Wait time between applying vacuum/water and start oftest: 30 MIN 30 MIN Test Start Time (TO: 9:OOAM 9:OOAM Initial Reading (Rj): 9" 9" Test End Time (TF): 10:OOAM 10:00AM Final Reading (RF): 9" 9" Test Duration (Tr. — Tj): 1 -HOUR 1 -HOUR Change in Reading (RF - Rj): 0 0 Pass/Fail Threshold or Criteria 0.00 0.00 Test Result: X Pass Fail X Pass Fall Pass Fail 0 Pass 0 Fail Comments — (include information on repairs made prior to testing, and recommendedfollow -upforfailed tests) CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING I hereby certify that all Cite information contained in this report is true, accurate, and infull compliance with legal requirements. Technician's Signature: — Date: 11 /17 /11 State laws and regulations do not currently require testing to be performed by a qualified contractor. However, local requirements may be more stringent. I RICH ENVIRONMENTAL 5643 BROOKS CT. BAKERSFIELD, CA. 93308 OFFICE (661)392 -8687 FAX (661)392 -0621 PRODUCT LINE LEAK DETECTOR TEST WORK SHEET W /0#: FACILITY NAME: HARRY'S MARKET #2 FACILITY ADDRESS: 2601 WHITE LN, BAKERSFIELD 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 10 PASS SERIAL # MECHANICAL PREM91 L/D TYPE: RED JACKET YES 10 PASS SERIAL # MECHANICAL L/D TYPE:- PASS YES SERIAL # - FAIL L/D TYPE: PASS YES SERIAL # FA1L 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: RICHARD MASON SIGNATURE: DATE: I1 /17/11 q4zs r T 2:UNLEADED IN -TANK SETUP SYSTEM SETUP PRODUCT CODE 1 THERMAL COEFF :.000700 NOV 16. 2011 8:59 Pt TANK DIAMETER 114.00 T 1:PREMTANKPROFILE1PTPRODUCTCODE 2FULLVOL12000THERMALCOEFF :.000700 SYSTEM UNITSTANKDIAMETER114.00 U.S. FLOAT SIZE: 4.0 IN. TANK PROFILE 1 PT FULL VOL 8000 SYSTEM LANGUAGE ENGLIENGLISH ILIMIT-' HHIIGHRWATER 2.5 FLOAT SIZE: 4.0 IN. MON D YYYY HH:MMFSS MAX OR LABEL VOL: 12000 OVERFILL LIMIT 90i WATER WARNING 2.0 GAS-N-00 2601WHITE LN 10800 HIGH WATER LIMIT: 2.5 BACKERSFIELD,CA HIGH PRODUCT 89% MAX OR LABEL VOL: 8000 1-661- 833 -8553 10680 DELIVERY LIMIT 10% OVERFILL LIMIT 9 7200 SHIFT TIME 1 : DISABL 1200 HIGH PRODUCT gg% SHIFT TIME 2 : DISABLSHIFT LOW PRODUCT 1200 7120 DELIVERY LIMIT : 89: SHIFT TIME 4 : DISABL LEAK ALARM LIMIT: 99 640SUDDENLOSSLIMIT: 99 TANK PER TST NEEDED W TANK TILT 0.00 PROBE OFFSET 0.00 LOW PRODUCT 500 DISABLED TANK ANN TST NEEDED WLEAKALARMLIMIT: 99 DISABLEDSUDDENLOSSLIMIT: 99 SIPHON MANIFOLDED TANKS TANK TILT 0.00 PROBE OFFSET 0.00 LINE RE- ENABLE METHOD TO: NONE PASS LINE TEST LINE MANIFOLDED TANKS TO' NONE SIPHON MANIFOLDED TANKS LINE PER TST NEEDED Wi LEAK MIN PERIODIC: 0: T4. NONE LINE MANIFOLDED TANKS LINELINE ANN TST NEEDED WIDISABLED 0 TO: NONE PRINT TC VOLUMES LEAK MIN ANNUAL : 0% LEAK MIN PERIODIC: 0r/. ENABLED 0 0 TEMP COMPENSATION PERIODIC TEST TYPE LEAK MIN ANNUAL 0•i VALUE (DEG F ): 60.0STICKHEIGHTOFFSET STANDARD 0 DISABLED DAYLIGHT SAVING TIME ANNUAL TEST FAIL PERIODIC TEST TYPE DISABLED ALARM DISABLED STANDARD PERIODIC TEST FAIL ALARM DISABLED ANNUAL TEST FAIL SYSTEM SECURITYALARMDISABLEDCODE : 000000 GROSS TEST FAIL ALARM DISABLED PERIODIC TEST FAIL CUSTOM ALARM LABELSALARMDISABLEDDISABLED ANN TEST AVERAGING: OFF GROSS TEST FAILPERTESTAVERAGING: OFF ALARM DISABLED TANK TEST NOTIFY: OFF ANN TEST AVERAGING: OFF TNK TST SIPHON BREAK:OFF PER TEST AVERAGING: OFF DELIVERY DELAY 1 MIN TANK TEST NOTIFY: OFF PUMP THRESHOLD : 10.00% TNK TST SIPHON BREAK:OFF DELIVERY DELAY 1 MIN PUMP THRESHOLD : 10.ON ALARM HISTORY REPORT SENSOR ALARM - - - -- L 1 :91TRUBINE STP SUMP SENSOR OUT ALARM NOV 16, 2011 10:05 PM FUEL ALARM NOV 16, 2011 9:49 PM FUEL ALARM OCT 29, 2010 12:56 PM ALARM HISTORY REPORT SENSOR ALARM - - - -- L 2:91FILL PIPING SUMP SENSOR OUT ALARM NOV 16, 2011 10:05 PM FUEL ALARM NOV 16, 2011 9:50 PM FUEL ALARM OCT 29, 2010 4:26 PM ALARM HISTORY REPORT - SENSOR ALAR11 SUMPU BT ' NE iB tEO 6 0 2011 01 Og Prl FUEL ALA2l 9:51 PM NOV 16 DUEL ALARM . W7 1>14 pyp,RM HISTORY REPORT SENOR ALARM - - a:g? FILL PIP1 SUMP OUT ' st4BO 6. 2011 10:05 KOV 16, 1p 0 9:52 wv F 22p10 4: t9 PM REPORT pL N15TOR A- - -- OSF1R LpW _ k2 p 5? oRERA A r105 N 16. 2p1 FOSL wq 16, 2011 9.57 PM v11EL ALA ZkA 10 3 :02 PM RECONCILIATION SETUP AUTOMATIC DAILY CLOSING TIME: 2:00 AM PERIODIC RECONCILIATION MODE: MONTHLY TEMP COMPENSATION STANDARD BUS SLOT FUEL -METER TANK TANK MAP EMPTY SOFTWARE REVISION LEVEL VERSION 123.02 SOFTWARE# 346123 -100 -C CREATED - 02.11.25.15.17 NO SOFTWARE MODULE SYSTEM FEATURES: PERIODIC IN -TANK TESTS ANNUAL IN -TANK TESTS OUTPUT RELAY SETUP R 1:UNLEADED SHUT -DOWN TYPE: STANDARD NORMALLY CLOSED LIQUID SENSOR ALMS ALL :FUEL ALARM ALL :SENSOR OUT ALARM F. 2:PREM SHUT -DOWN TYPE: STANDARD NORMALLY CLOSED LIQUID SENSOR ALMS ALL:FUEL ALARM ALL:SENSOR OUT ALARM LEAK TEST METHOD TEST ANNUALLY: ALL TANK. JAN WEEK 1 MON START TIME : DISABLED TEST RATE :0.20 GAL /HR DURATION : 2 HOURS TST EARLY STOP:DISABLED LEAK TEST REPORT FORMAT NORMAL LIQUID SENSOR SETUP L 1:91TRUBINE TRI -STATE (SINGLE FLOAT) CATEGORY : STP SUMP L 2:91FILL TRI -STATE (SINGLE FLOAT) CATEGORY : PIPING SUMP L 3:87TRUBINE TRI -STATE (SINGLE FLOAT) CATEGORY : STP SUMP L 4:87 FILL TRI -STATE (SINGLE FLOAT) CATEGORY : PIPING SUMP L 5:DISP 1x2 TRI -STATE (SINGLE FLOAT) CATEGORY : DISPENSER PAN L 6:DISP 3 *4 TRI -STATE (SINGLE FLOAT) CATEGORY : DISPENSER PAN L 7:DISP 5 *6 TRI -STATE (SINGLE FLOAT) CATEGORY : DISPENSER PAN L G:DISP 7x8 TRI -STATE (SINGLE FLOAT) CATEGORY : DISPENSER PAN L 9:ANNULAR TRI -STATE (SINGLE FLOAT) CATEGORY : ANNULAR SPACE ALARM HISTORY REPORT SENSOR ALARM - - - -- L 9:ANNULAR ANNULAR SPACE SENOR OUT ALARM NOV 16. 2011 10:05 PM FUEL ALARM NOV 15. 2011 9:53 PM FUEL ALARM OCT 29, 2010 1:02 PM COMMUNICATIONS SETUP PORT SETTINGS: NONE FOUND RS -232 END OF MESSAGE DISABLED ALARM HISTORY REPORT SENSOR ALARM - -- — L 6:DISP 3 *4 DISPENSER FAN SENSOR OUT ALARM NOV 16. 2011 11:05 PM FUEL ALARM NOV 16. 2011 9:55 PM FUEL ALARM OCT 29. 2010 5:35 PM ALARM HISTORY REPORT SENSOR ALARM - - - -- L+7:DISP 5 *6 DISPENSER PAN SENSOR OUT ALARMNOV16, 2011 10:05 PM FUEL ALARM NOV 16. 2011 9:59 PM FUEL ALARM OCT 29, 2010 1:06 PM ARM HISTORY REPORT SENSOR ALWA -- B :T11SP 7 *6A1gpEPiSERPAN SENSOR OUT ALARM NOV 16. 2011 10 05 PM FUEL ALARM NOV i 6. 2011 10:03 Pto4 FuEL ALARM OM 29, 2010 4:23 PM qf(o28 / MONITOR CERT. FAILURE REPORT SITE NAME : CT LkC' DATE : ADDRESS: 3--W) ( W kTf- TECHNICIAN: • CITY: ( K c k-D SIGNATURE : I THE FOLLOWING COMPONENTS WERE REPLACEDMEPAhtED TO COMPLETE TESTING. REPAIRS: I\J Q N LABOR: 6 PARTS INTALLED : NAME : TITLE: SIGNATURE: THE ABOVE NAMED PERSON TAKES FULL RESPONSIBILTTY 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.