HomeMy WebLinkAbout3200 F STREET (10)Pis
Appendix VI
Copies of Monitoring System Certification form and UST Monitoring Plot Plan available at htto: / /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 ofthis form to the local agency regulating UST systems within 30 days of test date.
A. General Information
Facility Name: Stuart Petroleum Mobil Bldg. No.:
Site Address: 3200 F St. City: Bakersfield Zip:
Facility Contact Person: John Stuart Contact Phone No.: ( 661 ) 325 -3620
Make /Model of Monitoring System: Veeder Root TLS 350 Date of Testing /Servicing:
1 / 24 / 2012
B. Inventory of Equipment Tested /Certified
Check the appropriate boxes to indicate specific equipment inspected /serviced:
Tank ID: 87 Tank ID: 91
X In -Tank Gauging Probe. Model: Veeder Root 846390XIn -Tank Gauging Probe. Model: Veeder Root 846390
Annular Space or Vault Sensor. Model: Annular Space or Vault Sensor. Model:
X Piping Sump / Trench Sensor(s). Model: Veeder Root 794380 X Piping Sump / Trench Sensor(s). Model: Veeder Root 794380
Fill Sump Sensor(s). Model: Fill Sump Sensor(s). Model:
Mechanical Line Leak Detector. Model: Mechanical Line Leak Detector. Model:
X Electronic Line Leak Detector. Model: Veeder Root 849490 X Electronic Line Leak Detector. Model: Veeder Root 849490
X Tank Overfill / High -Level Sensor. Model: Veeder Root 846390 X Tank Overfill / High -Level Sensor. Model: Veeder Root 846390
Others eci 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:
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 Sensor(s). Model: Piping Sump / Trench Sensor(s). Model:
7 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:
Others eci a ui ment type and model in Section E on Page 2). Other (specily equipment t e and model in Section E on Pa e_).
Dispenser ID: 1 -2 Dispenser ID: 3-4
X Dispenser Containment Sensor(s). Model: BEI -406 X Dispenser Containment Sensor(s). Model: BEI -406
X Shear Valve(s). X Shear Valve(s).
Dispenser Containment Floats and Chain(s). Dis enser Containment Floats and Chain(s).
Dispenser ID: 5 -6 Dispenser ID: 7 -8
X Dispenser Containment Sensor(s). Model: BEI -406 X Dispenser Containment Sensor(s). Model: BEI -406
X Shear Valve(s). X Shear Valve(s).
Dispenser Containment Floats and Chain(s). Dispenser Containment Floats and Chains .
Dispenser ID: 9 -10 Dispenser ID: 11 -12
X Dispenser Containment Sensor(s). Model: BEI -406 Dispenser Containment Sensor(s). Model:
X Shear Valve(s). Shear Valve(s).
Dispenser Containment Floats 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 re .ports, I have also attached a
copy of the report; (check all that apply): System set -up Alarm history report
Technician Name (print): Stewart Bradly Signature:
Certification No.: 8141938 -UT License. No.: 481053
Testing Company Name: Kem County Construction, Inc Phone No.:( 661 ) 634 -9950
Testing Company Address: PO Box 6096, Bakersfield, CA 93386 Date of Testing /Servicing: 1 / 24 / 2012
Monitoring System Certification Page 1 of 4 12/07
2/21/07
D. Results of Testing/Servicing
Software Version Installed:
Complete the following checklist:
X Yes No` Is the audible alarm operational?
X Yes No* Is the visual alarm operational?
X Yes No* Were all sensors visually inspected, functionally tested, and confirmed operational?
X Yes No* Were all sensors installed at lowest point of secondary containment and positioned so that other equipment will not interfere with their
roper operation?
Yes No* If alarms are relayed to a remote monitoring station, is all communications equipment (e.g. modem) operational?
X N/A
X Yes No* For pressurized piping systems, does the turbine automatically shut down if the piping secondary containment monitoring system
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; Dispenser Containment Sensors. Did you confirm positive shut -down due to leaks and sensor
failure /disconnection? X Yes; No.
X Yes No* For tank systems that utilize the monitoring system as the primary tank overfill warning device (i.e. no mechanical overfill prevention
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
of tank capacity does the alarm trigger? 90 %
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* 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.
X Yes No* Was monitoring system set -up reviewed to ensure proper settings? Attach set up reports, if applicable
X Yes 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.
Comments:
2/21/07
Monitoring System Certification
Page 2 of4
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 No* Has all input wiring been inspected for proper entry and termination, including testing for ground faults?
X Yes No* Were all tank gauging probes visually inspected for damage and residue buildup?
X Yes No* Was accuracy of system product level readings tested?
X Yes No* Was accuracy of system water level readings tested?
X Yes No* Were all probes reinstalled properly?
X 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): Check this box if LLDs are not installed.
Complete the following checklist:
X Yes 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: X 3 g.p.h.; 110.1 g.p.h ; 0.2 g.p.h.
X Yes No* Were all LLDs confirmed operational and accurate within regulatory requirements?
X Yes No* Was the testing apparatus properly calibrated?
X Yes No* For mechanical LLDs, does the LLD restrict product flow if it detects a leak?
N/A
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?
Yes 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?
Yes No* For electronic LLDs, have all accessible wiring connections been visually inspected?
X N/A
X 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:
Monitoring System Certification Page 3 of 4 12107
4 2/21/07
Monitoring System Certification
UST (Monitoring Site Plan
Site Address: 'E-L& y F U <
J
7
L1 i_1 ...............
74-Z. . . . . . . . . . . . . . . . . . .
Date map was drawn: I / 7L1 /fZZ.
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 Deport Form
Thisform is intendedfor use by contractors performing annual testing ofUST spill containment structures. The completedform and
printouts from tests (ifapplicable), should be provided to thefacility owner /operatorfor submittal to the local regulatory agency.
1. FACILITY INFORMATION
Facility Name: Stuarts Petroleum Mobil Date of Testing: 1 -24 -12
Facility Address: 3200 F St.
Facility Contact: John Stuart Phone: 661- 325 -6320
Date Local Agency Was Notified of Testing : 1 -17 -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: Stewart Bradly
Credentials': X CSLB Contractor X ICC Service Tech. SWRCB Tank Tester Other (Specify)
License Number(s): 481053 8141938 -UT
3. SPILL BUCKET TESTING INFORMATION
Test Method Used: XHydrostatic Vacuum Other
Test Equipment Used: Visual Equipment Resolution: 0.0"
Identify Spill Bucket (By Tank
Number, Stored Product, etc.
1 87 2 91 3 4
Bucket Installation Type: X Direct Bury
Contained in Sump
X Direct Bury
Contained in Sump
X Direct Bury
Contained in Sump
Direct Bury
Contained in Sum
Bucket Diameter: 1 1" 11"
Bucket Depth: 15" 16"
Wait time between applying
vacuum/water and start of test: 15 Min. 15 Min.
Test Start Time (Ti): 11:30 11:30
Initial Reading (Rj): 9" 8.5"
Test End Time (TF): 12:30 12:30
Final Reading (RF): 9" 8.5"
Test Duration (TF — Tj): 1 Hr. 1 Hr. 1 Hr.
Change in Reading (RF- Ri): 0.0" 0.0" 0.0"
Pass /Fail Threshold or
Criteria: 0.0" 0.0" 0.0"
Test Result: X Pass Fail X Pass Fail Pass Fail Pass Fail
Comments — (include information on repairs made prior to testing, and recommendedfollow -up forfailed tests)
CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING
I hereby cert ft that all the information contained in this report is true, accurate, and in full compliance with legal requirements.
Technician's Signatu dc/ Date:
State laws and regulations do not currently require testing to be performed by a qualified contractor. However, ocal requirements
may be more stringent.
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