HomeMy WebLinkAbout300 FAIRVIEWBSSR, Inc.
6630 Rosedale Hwy., # B, Bakersfield, CA 93308 Phone (661) 588 -2777 Fax (661) 588 -2786
1. MONITORING SYSTEM CERTIFICATION
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: VA I 1Z J t E 6.) T 2 Utr LC Bldg. No.:
Site Address: 30n TA 19Ni 1 E \,L) city: ( sFt>>; Zip:
Facility Contact Person: A rA R 1 K Pia Q V.p Contact Phone No.: 3 (,
Make/Model ofMonitoring System: QdK, ATl Date of Testing/Servicing: 16 / 10
B. Inventory of Equipment Tested /Certified
Check the appropriate boxes to Indicate specific eauioment Insvected/seryIced:
Tank ID: b i 1` -s E L Tank fD:
O In -Tank Gauging
Pry
obe.— Model: Q In -Tank Gauging Probe. Model:
Annular Space or Vault Sensor. Model: Ro iJ Aoj Annular Space or Vault Sensor. Model:
WPiping Sump / Trench Sensor(s). Model: J_ptr l A KI Piping Sump / Trench Sensor(s). Model:
QY-Tdl Sump Sensor(s). Model: 0 O 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: O Tank Overfill / High -Level Sensor. Model:
Other(specify equipment a and model in Section E on Page 2). O Other Uecify equipment a and model in Section E on Page 2).
TanklD: Tank lD:
O In -Tank Gauging Probe. Model: O In -Tank Gauging Probe. Model: _
Annular Space or Vault Sensor. Model: Annular Space or Vault Sensor. Model: _
Piping Sump / Trench Sensor(s). Model: O Piping Sump / Trench Sensor(s). Model:
Fill Sump Sensor(s). Model: O Fill Sump Sensor(s). Model:
Mechanical Line Leak Detector. Model: O Mechanical Line Leak Detector. Model: _
Electronic Line Leak Detector, Model: Electronic Line Leak Detector. Model:
Tank Overfill / High -Level Sensor, Model: O Tank Overfill / High -Level Sensor. Model:
Other s ecif ui ment tae and model in Section E on Pa e 2 . Other s ecif a ui ment a and model in Section E on Page 2).
Dispenser ID: j D l E E L DispenserID:
VDispenser Containment Sensor(s). Model: FSFR j bZA 1 Dispenser Containment Sensor(s). Model:
WShear Valve(s). Qp R Shear Valve(s).
Dispenser Containment Floats and Chain(s). Dispenser Containment Floats and Chain(s).
Dispenser ID: Dispenser ID:
Dispenser Containment Sensor(s). Model: O Dispenser Containment Sensor(s). Model:
Shear Valve(s). Shear Valve(s).
Dispenser Containment Floats and Chain(s). O Dispenser Containment Floats and Chain(s).
Dispenser ID: Dispenser ID:
Dispenser Containment Sensor(s). Model: Dispensei Containment Sensor(s). Mode!:
O Shear Va!ve(s). Shear Valve(s).
Dis enser Containment Floats and Chain(s). O Dispenser Containment Floats and Chain(s).
If the faeility contains more tanks or disnensers. coov this form. Include information for every tank and dispenser at the facility.
r
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 all that apply): Syste set -u O Alarm history report
Technician Name (print): 161 L C A 1212-1 L LO Signature:
Cei•tiiication No.: License. No.:
Testing Company Name: 5a 2 1 tsl C, Phone No.:(
Site Address: b63U (Zp Fb A LE l-tb.3 q 4 Date of Testing / Servicng: (
Page 1 of 3 03iut
Monitoring System Certification
SWRCB, January 2006
Spill Bucket Testing Report Form
This form i. intendedfor use by contractors performing annual testing ofUST spill containment structures. The completedform and
printoutsfrom tests (ifapplicable), should be provided to the facility owner /operatorfor submittal to the local regulatory agenc>>.
1. FACILITY INFORMATION
Facility Name: C Date of Testing: _ 16- to
Facility Address:
Facility Contact: Phone:
Date Local Agency Was Notified of Testing :
Name of Local Agency Inspector (ifpresent during testing): >E (L rA t C ME p k Ny A
2. TESTING CONTRACTOR INFORMATION
Company Name: C.,
Technician Conducting Test:
Credentials: N SLB Contractor YTCC Service Tech. 0 SWRCB Tank Tester 0 Other (Specify)
License Number(s): — U "r C 5 Le, 4 -jA 8
3. SPILL BUCKET TESTING INFORMATION
Test Method Used: & drostatic Vacuum 0 Other
Test Equipment Used: Equipment Resolution:
Identify Spill Bucket (By Tank
Number, Stored Product, etc.
1 1 5 E 2 3 4
Bucket Installation Type: I Direct Bury
WContained in Sum
0 Direct Bury
Contained in Sum
Direct Bury
0 Contained in Sum
0 Direct Bury
0 Contained in Su m )
Bucket Diameter: 11
Bucket Depth:
Wait time between applying
vacuum/water and start of test: 10 M t aJ
Test Start Time (Ti): 00 Awl
Initial Reading (R,):
Test End Time (TF): 1,
Final Reading (RF) : 4-.1.704
Test Duration (TF — T)):
Change in Reading (RF - Ri):
Pass/Fail Threshold or
Criteria:
Test Result: Gass Fall 0 Pass Fall 0 Pass Fail j Pass Fail
Comments — (include information on repairs made prior to testing, and recommendedfollow -up for failed tests)
CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING
I hereby certify that all the Information contained In this report Is true, accurate, and In full compliance with legal requirements.
Technician's Signature:_ CL Q C WAAA &A.& Date: la— t &— In
State laws and regulations do not currently require testing to be performed by a qualified contractor. However, local requirements
mev )gyp rnnrn ctrinnonf
0, Results of Testing /Servicing
Software Version Installed:
Complete the following checklist:
i & Yes Cl No* Is the audible alarm operational?
f'es No* Is the visual alarm operational?
es No* Were all sensors visual) ins ected functional) tested and confirmed o erational?
Yes
CS
No* Were all sensors installed at lowest point of secondary containment and positioned so that other equipment will
not interfere with their ro er o eration?
Yes No* If alarms are relayed to a remote monitoring station, is all communications equipment (e.g. modem)
0 N/A operational?
Cl 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) O Sumparench Sensors; Dispenser Containment Sensors.
Did you confirm positive shut -down due to leaks lad sensor failure /disconnection? Yes; No.
CO] 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 ro erl ? If so at what percent of tank capacity does the alarm trigger? %
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 E below.
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.
Cl Yes No* Was monitoring system set-up reviewed to ensure proper settings? Attach set up reports, if applicable
Sr Yes No* Is all monitoring a ui ment o erational 2er manufacturer's s ecifications?
In Section E below, describe how and when these deficiencies were or will be corrected.
E. Comments: !A t-J 4C 1"0s_\ ES
0 R2%tJl TE lz -
t I E 11 f-t B (a 1 L TLO(- s EQ IZ _ —_ --
d `I E iZ 'F t_ L R E \l E tJ i10 r J D Eel t C E
Page 2 of 3 03/01
F. In -Tank Gauging / SIR Equipment: O 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.
Coinplete the following checklist:
Yes O No* Has all input wiring been inspected for proper entry and termination, including testing for ground faults?
O Yes No* Were all tank gauging probes visually inspected for damage and residue buildup?
Yes No* Was accuracy of system product level readings tested?
Yes No* Was accuracy of system water level readings tested?
Yes No* Were all probes reinstalled. properly?
O 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 he corrected.
G. Line Leak Detectors (LLD):
Complete the following checklist:
Check this box if LLDs are not installed.
Yes No* For equipment start-up or annual equipment certification, was a leak simulated to verify LLD performance? Gir
N/A Check all that apply) Simulated leak rate: 5n g.p.h.; 0.1 g.p.h; 0.2 g.p.h.
Yes C3 No* Were all LLDs confirmed operational and accurate within regulatory requirements?
Yes O No* Was the testing apparatus properly calibrated?
CiYYes No* For mechanical LLDs, does the LLD restrict product flow if it detects a leak?
N/A
Yes O 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
5d N/A or disconnected?
0 Yes No* For electronic. LLDs, does the turbine automatically shut off if any portion of the monitoring system
N/A malfunctions or fails a test?
Yes No* For electronic LLDs, have all accessible wiring connections been visually inspected?
3 N/A
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.
H. Comments:
Page 3 of 3 03101
Monitoring System Certification
LIST Monitoring Site Plan
Site Address:
OF.CE
Vj . . .. . . . . . . . : . . . . . :
Fi Lp. $vi ria. . . . . . . . . . . : . . . . . . . . . . . . .
I ......... I.................
I........
I.........
I .......... I ......
Date mgp was drawn: I;L / 16 / 10
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.
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