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HomeMy WebLinkAboutFMC 2011e4/11/2e12 13: 58 0000000000 01`_ t`_ 9: I` _I`_I`_t`_t`_I`_t`_ftt`_t`_0N PAGE 01/05 Appendix VI Copies of Monitoring System Certification form and UST Monitoring Plot Plan available at htIy: ffi ww,waterboards. .00v.) MONITORING SYSTEM CERTIFICATION For Use ByAll Jurisdictions Within the State ofCallfomie Authority Cited: Chapter 6.7, Health and Safety Code; Chapter 16, Division 3, 17Ue 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 technldan 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 th form to the local agency regulating UST systems within 30 days oftest date, A. General infer Facility Name. Site Address: No.; zip: ?-3 V7 Facility Contact Person; Contact Phone No.: (_ / Make/Model of Monl oring System; G, sh Dote of Testing/Servicing: J7 / B. Inventory of Equipment Tested/Certifled Check the appropriate boxes to Indicate specific equipment Insoected/serviced: Tank ID: y Tank ID: Le In -Tank Gauging Probe. Model;; e4" In•Tank Gauging Probe, Mader: 174 Go rf' Annular Space or Vault Sensor, Model; , / DIcAnnular Space or Vault Sensor. Model; fit/ t$ Piping Sump / Trench Sansor(s). Modal: &&u X Piping Sump / Trench Sensor(s), y= Model Fill Sump Sensor(sy Model; n Fill Sump Sensor(s). Model; n Mechanical Une Leak Detector. Model: Mechanical Line Leak Detector. Model: 0 Eloctronle Line Leak Detector. Model Electronic Une Leak Detector. Model: n Tank Overfill / High -Level Sensor, Model: Tank Overfill / High -Level Sensor. Model: Other (speclN m ul ment type and medal In Section E on Pon 2). Other (s22cl uipment = and model in Section E on Page 2). Tank ID: Tank ID: Ar In -Tank Gauging Probe. Model: In -Tank Gauging Probe. Model: aleAnnular Space or Vault Sensor. Model; C Annular Space or Vault Sensor. Model; R Piping Sump I Trench Sensor(a), Model: Plping Sump / Trench Sensor(s), Motlel: ap u Fill Sump Senors). Model: Fill Sump Sensor(s). Model: Cl Mechanlcal Line Leak Detector. Model: 11 Mechanical Line Leak Detector. Model: Electronle Line Look Detector. Model: Electronic Line Leak Detector. Model: U Tank Overfill / High -Leval Sensor, Model: Tank Overfill I High -Level Sensor, Model: Other (Specify ul ment jygS and model In Section E on Page 2), 0 Others d e ul merit gg and model in Section E on Page Di 1 Dispensereser 7 Dispe seridr- Dispenser en ainme SSnsor(s), Model: DispDlepeneKCOntelnmen Sensor(s), Modal: Il Shear Valve(s), n Shear Valve(s). Dispenser Containment Floats and Chaln s , Dispenser Containment Floats and Chains . Dispenser ID: 2061 Dispenser ID: A Dispenser Containment nsor(s). Model; Dispenser Containment ensor(e). Model: 0 Sheer Valve(s), Sheer Valve(s). Dispenser Containment Floats and Chains . f Di eraser Containment Floats and Chains . Dlsponsor ID: Dispenser ID: 4 Dispenser Containme Sensor(a). Model: n Dispenser Containment Sensor(s). Model: Shear Va"(s). Shear valve(s), Ofs-penser Containment Float a and Chains U Dia nser Containment Floats and h in s , iT the farway contains morn tanks or dispensers, copy this form. Include Information for every tank and dispenser at the facility. C. Certlflcatibn - I certify that the equipment Identified In this document was Inspectedlserviced 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 genorating Such reports, I have also attached a copy of the report: (check all that apply): System set-up n Alarm history roport Technician Name (print): .A/t? S Signsture; Certificaflon No.: License. No.: L49101 3 Testing Company Namo: Phone No.:( Testing Company Address: I r° Date of Tasting/3orvldng: i l Monitoring System CertIflcabon Page t of 4 12/07 2/21/07 0. Rbsults of Testing /Servicing Software version Installed: IA—_ Comnlete the fallmAna checkflst: Yes No' Is t audlble alarm operational? Yes n Ne Is the visual alarm operational? Yes o' Were all sensors sual Ina eared, functionally test . and confirmed operational? Yes 0 Ne Were all sensors Installed at lowest point of secondary containment and positioned so that other equipment will not Interfere with their proper e ration? 11 Yes I.] No' If alarms are relayed to a remote monitoring station, Is aU communications equipment (e.g. modem) operational? N/A Yes n lie For pressurized piping systems, does the turbine automatically Out down if the piping secondary containment monitoring system N/A detects a leak, falls to operate, or Is electrically disconnected? If yes: which sensors Initiate positive shut -down? (Check ell that eppiyj Sump/Tronch sensors; o Dispenser Containment Sensors. Did you confirm positive shut -down due to looks &d sensor fallure /dlsconnB i n? g Yes; CI No. Yes o For tank systems that utilise the monitoring system as the primary tank overfill waminq device (I.e. no mechanical overfill prevention j;C N/A valve Is Installed), is the overfill warning alarm visible and audlbte at the tank flil polrn(s) and operating property? If so, at what percent of tank cepacIty does the alarm IdggPr7 7k U 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 a In Section E below, la Yes' Fr. No Was liquid found Inside any secondary containment systems designed as dry systems? (Chack allthat apply) n Product; CJ Water, If s doscrlbe causes In action E below. es ii No` Was monitoring system set-up reviewed to ensure proper settings? Attach sot up reports, if applicable Yes I 1 No' Is all monitoring equipment operational per manufacturer's specifications? n eetion E low, desc Ibe how and when these deficlencles were or will be corrected. Commenta- Monitoring System Certification page 2 of a 12/07 2/21/07 tea. 1H4. 11198 via VSI -FAX Page 1 04/11/2012 13:58 0000000000 PAGE 03/05 F. In -Tank Gauging / SIR Equipment: "I Check this box if tank gauging is used only for Inventory control. n 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. Comolata tho fnllnwlno checklist: Yes n No' Has all input wiring been Inspected for proper entry and termination, including testing for ground faults? U Yes 0 No' Were all tank gauging probes visually inspected for damage and residue buildup? 0 Yes u No' Was amm y of system product level readings tested? I_i Yes n No' Was accuracy of system water level readings tested? ii Yes n No' Were all probes reinstalled properly? u Yes 0 No' Were all items on the equipment manufacturer's maintenance checklist completed? In the Section H, below, describe how and when these defieleneies were or will be corrected. G. Line Leak Detectors (LLD): Li Check this box if LLDs are not Installed. Complete the fnllnwlna checkllst: Yes n No` For equipment start -up or annual equipment certNlcetlon, was a leak simulated to verify LLD performance? (Chock all7ciNIAthatapply) Simulated leak rate: 3 g.p.h.; a 0.1 g.p.h ; D 0.2 g.p.h. Yes 0 No' Were all LLDs confirmed operational and accurate within regulatory requirements? y Yes l:l No' Was the testing apparatus properly calibrated? Yes u No' For mechanical LLDs, does the LLD restrict product flow if a detects a leak? I N/A Yes u 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 or N/A disconnected? U Yes n No- For electronic LL s, does the turbine automatically shut off if any portion of the monitoring system malfuncllons or N/A fails a test? Cl Yes n No' For electronic LLD9, have all accessible wiring Connections been visually inspected? N/A Yes ii NW Were all items on the equipment manufacturer's maintenance checklist completed? In me 3ecuon m. oeiow, aesurroe now eno wnen inese oenapencles were or Will Be GOrregme. H. Comments: Monitoring system Certification Page 3 of 4 12107 3 2/21/07 04/11/2012 13:58 0000000000 PAGE 04/05 Monitoring System Certification UST Monitoring Site Plan Site Address: M1 -;n ye Date map was drawn; 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 contalners, 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 dato this Site Plan was prepared. Monitoring Sy4tem Certification Page 4 of 4 12107 4 2/21/07 04/11/2012 13: 58 0000000000 0(t t-`_ft91t t_`1tftftON PAGE 05/05 o SWRCB, January 2006 Spill Bucket Testing Report Form Thisform is intendedfor use by contractors performing annual testing ofUST spill containment structures. The completedforn9 and printoutsfrom rests ((fapplicable), should he provided to thefacilihi owner /operatorfor .submittal to the local regulatory agency. 1. FACILITY INFORMATION Facility Name: Q _ 5 Date of Testing: Facility Address: ' Facility Contact: Phone: Date Local Agency Was Notified o resting : Name of Local Agency Inspector (ifpresent during testing): It TrQrrtVr_ rnV1rUA r+TnR TNFnRMATTON Company Name: Y Dry Technician Conducting Test: t!.-Q Credentials': L CSL13 Contractor XICC Service Tech. 0 SWRCB Tank Tester Other ecii License Number(s): A GPH.T. RUrKFT TFCTTNr. TWORMATION Test Method Used: Hydrostatic Vacuum Other Test Equipment Used: Equipment Resolution; Id Spill )3ueket (Dy Tookentify Number, Stored Product, etc. 1 2 lJ / 1 3 n /J C -C 4 Bucket Installation Type: fi?- Direct Bury Containd in SumL XDirect Bury Contained in Sump Direct Bury Contained in Sump Direct Bury Contained in Sutn Bucket Diameter: 1214 12, Bucket Depth: 7 Wait time between applying vacuum /water and start of test: Test Start Time (T): Initial Reading (Rr): Test End Time (T.P): Final Reading (RF): Test Duration (Tp — TI); Change in Reading (R,: - Rj); Pass/Fail Threshold or CTi.teri.a: esi Res6If: D, ,Pass, I'gilia9s. Fa;l. Puss M.)Fail D PAgs: lFaiI Components — (include information on repairs made prior to testing and recommendedfollow -up for failed tests) CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING hereby certiftr Iitat all the information contained In this report is true, accurate, and in.ruff compliance with legal requirements. Technician's Signature: Date: State laws and regulations do not currently require testing to be performed by a qualified contractor. However, local requirements may be more stringent.