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Home My WebLink About3500 GILMORE AVENUE (9)Appendix V! Copies of Monitoring System Certification form and UST Monitoring Plot Plan available at httn://www.waterboards.ca.gpv.) MONITORING SYSTEM CERTIFICATION For Use By ANJurisdictions Wdhin the State of California Authority Cited: Chapter 6.7, Health and Safety Code; Chapter 16, Dly1slon 3, Me 23, Califomla 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 oftest date. A. General information / Facility Name: kfA'.- ei Y,, r6, ,a ri2,/ Bldg. No.: 7 Site Address: !kzal za-1 t- 4-4 '" city: 11, ffeks6t l zip: 9.30 9 Facility Contact Person: —LNLdCL Cit tY Contact Phone No.: t d / I S 14--1 7 Z f Maka/Model of Monitoring System: _ZCt r l207- Date of Testing/Servidng: 01 t B. Inventory of Equipment. Tested/Certified Check the Epropriste boxes to Indicate specific equipment ins ed/serviced: Tank ID: Tank iD: Ij -&Tank auging Probe. Model: 0 In -Tank Gauping Probe. Model: p- Annular Space or Vault Sensor. Model: ,C tinr 0 AnnularSpace orVault Sensor. Model: IYF liping Sump / Trench Sensor(s). Model: CL-,M,4 s'f"hnr— Piping Sump / Trench Sensor(s). Model: 0 FiI Sump Sensor(s). tr-Mechanical Line Leak Detector. Model: Model: L 0 Fill Sump Sensor(s). Model: 0 Electrode Line Leak Detector. Model: Mechanical Line Leak Detector. Electronic Line Leak Detector. Model: Model: O Tank Overfill / High-Level Sensor. Model: Tank Overfill / High -Level Sensor. Model: 0 Others equipment and model In Section E on P! 2e 2). 0 Other a and model In Section E on Page 2). Tank iD: Tank ID: e tn -Tan augIng Probe lpnuiar space or vauf< Sensor. Model: Model: F ,y.c:,, O In -Tank Gauging Probe. Model: uE IP49ng Sump /Trench Sensor(s). e,. Model: A ,f f4jnr AnnularSpace orVault Sensor. O Piping Sump / Trench Sensor(s). Model: Model: fA Sump Sensor(s). Model: 0 Fill Sump Sensor(s). Model: echanical Line Leak Detector, Model: / A 0 Mechanical Line Leak Detector. Model: Electronic Line Leak Detector. Model: 0 Electronic Una Leak Detector. Model: 0 Tank Overfill / High -Level Sensor. Model: Tank Overfill / High -Level Sensor. Model: O Other mart and model fn Section E on Pa e 2 .. Other Lsgecl 29L and model In Section E on Pa 2). Dispenser ID: — Dispenser 10: Spenser Containment Sensor(s). B Show Valve(s). Model: I penser Containment Sensor(s). Model: 9,'Shear valve(s). 0 Dis Containment Floats and Chaln s . 0 Dis Containment Floats and Chain(s). Dlspenser10: — Dispenser 10: j9penser Containment Sensor(s). Model: O Dispenser Containment Sensor(s). Model: - r9-5 KW Valve(s). Shear Valve(s). 0 Dis enserContakment Floats and Choln s . O Dls MVContairunent Fload s and Chains . DispQeenser im. - _5--6 Dispenser ID: a- 'Dispenser Containment Sensor(s). it Model: S IzA 0 Dispenser Containment Sensor(s). Model: ttliShearValve(s). . ShearValve(s). 0 enser Containent Floats 'and Chal s" I Dispenser Containment Floats and Chain(s). L n the rachmy careen mare ranks or dispensers, copy this term. Include information for every tank and dispenser at the facility. C. Certification - 1 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 correctandaPlotPlanshowingthelayoutofmonftoringeeqquipment. For any equipment capable of generating such reports. I have also attached acopyofthereport; (checkall dratapply): tam set-up giM his report Technician Name (print): Z'TC, Zl e,, Signature: CertlflcaUon No.' j< 2 -7 1C, l barns . o.: 2M-b d Testing Company Name: — Phone No.:( 7 —y t y Testing Company Address: 'I !jx-= r, ,.` r, eT &41.ex5Z• fM.V Date ofTesting/SerAcing :1 1'J fl Monitoring System Certification Page 1 01`4 12107 2/21/07 D. Results ofTesting/Serviccing Software version Installed: Complete the following checklist: Yes 0 No' Is the audible alarm operational? No` Is the visual alarm operational? Yes 0 No* 1 Were all sensors visually inspected, functionally tested, and confirmed operational? aiLas r Yes 0 No' Were all sensors Installed at lowest point of secondary containment and positioned so that other equipment will not Interfere with their er operation? U Yes 0 /Nci' 11 alarms are relayed to a remote monitoring station, Is ati communications equipment (e.g• modem) operational? V N/A Yes D No' For pressurized piping systems, does the turbine automatkwlly shW down If the piping secondary containment monitoring system 0 N/A dels a leak, falls to operate, or is electrically disconnected? If yes: which sensors inriiate positive shut -down? (Checkadthat OAP/y) USumprrrench Sensors- O Dispenser Containment Sensors. Did you confirm positive shut -down due to leaks goal sensor fallureldiscmnection? Pres• O Na O Yes o No' For tank systems that utilize the monitoring system as the primary tank overfill waming device (i.e. no mechanical ov U prevention p N/A valve is Installed), Is the overfill warning alarm visible and audible at the tank fiG point($) and operating property? if so, at what percent oftank capacilty doesthe alarm t OA 0 Yes* No Was any monitoring equipment replaced? If yes, Identify spdcffic sensors, probes, or other equipment replaced and list the manufacturer name and model for all replacement earts in Section E below. 0 Yes* No Was Ikluid found Inside any secondary containment systems designed as dry systems? (Check all that apply) 0 Product; 0 Water. I Yes. describe causes in Section E. below. ff es 0 NO* Was monitoring system set -up reviewed to ensure propersettings? Attach sot up reports, if applicable IV Yes 0 NW Is all monitoring equipment operational permenu ref's specifications? In Section E below, describe how and when these deficlencies were or will be corrected. I- Comments: Monitoring System Certification Page 2 of 4 12107 2 2/21/07 i Monitoring System Certification Page 2 of 4 12107 2 2/21/07 F. In -Tank Gauging / SIR Equipment Check this box if tank gauging is used only for inventory control. 0 Check this box if no tank gauging or SIR equipment is installed. This section must be completed if in4ank gauging equipment is used to perform leak detection monitoring. Camninte the fnilnwrnn rharNiah Yes No' Has all input wiring been Inspected for proper entry and termination, including testing for ground faults? 0 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 0 No' Were all probes reinstalled pmperty'T Yes 0 No' Were all items on the equipment manufacturer's maintenance checklist completed? in the becuon n, below, describe how and when these deficiencies were or will be corrected. G. Line Leak Detectors (LLD): 0 Check this box if LLDs are not installed. Cnnu lwtw the MlInuwnn rhar_kl:et- In the Section H, below, describe how and when these deficiencies were or wit be corrected. H. Comments: Monitoring System Certification Page 3 of 4 12107 2/21/07 No' For equipment start -up or annual equipment certification, was a leak simulated to verify LLD performance? (Check alt 0 NIA thatapply) Simulated leak rate: 93 g.p.h.; 0.1 g.p.h; 0 0.2 g.p.h. No' Were all LLDs confirmed operational and accurate within regulatory requirements? 0 No' Was the testing apparatus property calibrated? ly 0 No' For mechanical LLDs, does the LLD restrict product flow if it detects a leak? 0 N/ArYe00' For electronic LLDs, does the turbine automatically shut off ifthe LLD detects a leak? WA No' For electronic LLDs, does the turbine automatically shut off If any portion of the monitoring system is disabled orNIAdisconnected? No' For electronic LLDs, does the turbine automatically shut off if any portion of the monitoring system malfunctions or NIA falls a test? 0 No' Forelectronic LLDs, have all accessible wiring connections been visually Inspected? N/A Yes 0 No* Were all hems on the equipment manufacturers maintenance checklist completed? In the Section H, below, describe how and when these deficiencies were or wit be corrected. H. Comments: Monitoring System Certification Page 3 of 4 12107 2/21/07 h y I Monitoring System Certification UST Monitoring Site Plan Site Address: 10 i 'ryu_ -IfelA i r i-r (d CA t UPI A/ . . . . . . . . . . . . . . . . . . . . . . . . . . . I . . . . . . I............ I.................. I.......................... I . . . . . . . . . . . . . . . . . . . . . . . . I . . . . . . . . . . . . . . . . I.................. I...........I.................. I.............. F49 ................ . tbc w /A P .# ....... r I .......... I............ I...... Date map was drawn:. O1? If you already have a diagram that shows all required information, you may include it, rather than this page, with your Monitoring SystemCertiicetlon. 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 teak detection). In the space provided, note the date this $Re Plan was prepared. MonRortng System Certification Page 4 of 4 12107 4 2/21/07 0 CV Cal - valley Equipment 3500 Gilmore Ave. Bakersfield, CA 93308 661 -327 -9341 FAX# 661 - 325 -2529 VAPORLESS MANUFACTURING, INC. LDT -890 Leak Detector Test Record Contractor Custome E_ is - • .• • 22y-2mg Y!n/ Tr rug, Avc• C r,rC>'.vs .e/d_, Dlese/ Technician Submersible Pump Identification Manufacturer Model No. Serial Number e fYt? Leak Detector Identification Manufacturer Description Other Style Leak Detector Diaphragm -type Piston -type if Tamper -proofseal installed? Yes No Leak Detector in Submersible Pump Test at Dispenser 1. Operating Pump Pressure ___Z Psi (para. 15) Gallons per hour rate 3. d (para. 22) 3. Line pressure with pump shut off4- psi (para. 23) 4. Bleedback Test with pump off , ml (para. 26) 5. Step - through time to full flow : seconds (pars. 30) 6. Leak detector stays in leak search position. (para.42) Yes ' No LEAK DETECTOR TEST Note: Pass - Leak detector fits test protocol Fall — Leakdeteetor fails testprotocol Pass Fail Form 890C(9 -1 -96) *Complete thermal expansion test before failing leak detector. 1996 Vaporless Manufacturing, Inc., Prescott Valley, AZ CVE Cal - valley Equipment 3500 Gilmore Ave. Bakersfield, CA 93308 661 - 327 -9341 FAX# 661 - 325 -2529 VAPORLESS MANUFACTURING, INC. LDT -890 Leak Detector Test Record Contractor Customer com ti- C/4 C a _ Date 'Location ' Product 12.: 2 y -2eog Z1101 Tr-ux7`4k, Ale. 77 vG. -- - Technician Manufacturer Model No. Serial Number Leak Detector Identification Manufacturer Description Other Style Leak Detector 1'a G k Diaphragm -type Piston -type 'e_ Tamper -proof seal installed? Yes No Test at Dispenser 1. Operating Pump Pressure__ZG __psi (para. 15) 2. Gallons per hour rate '3. d (para. 22) 3. Line pressure wfth pump shut off 2.0 psi (para. 23) 4. Bleedback Test with pump off s512 mi (para. 26) 5. Step - through time to full flow seconds (para. 30) 6. Leak detector stays in leak search position. (para.42) Yes y' No LEAK DETECTOR TEST Note: Pass - Leak detector fits test protocol Fail b Look detector fails test protocol Pass Fail Form 890C(9 -1 -96) 'Complete thermal expansion test before failing ieak detector. 1996 Vaporless Manufacturing, Inc., Prescott Valley, AZ AE'SVLT- ions arr, fir: Lee *I : UNE UNE #3: P 31ieficl - tM6.011 We" 359.0 Gilmore A Bal s €iad, CA 93 61- 327 -9341 paa #661- 325 -255'9 EK W 2dot was Ole %Vkxre d WOWW 91 tW tv* 06 F s7 4's MMOV @pGMW3j I. V#*Mva CCP+NW:{ 9 iF ri A IICiYQ SQCftiE i7. n'1@ C.p' .tTVf¢S{Dl'1 COt1 6R0 PX 4 6S'i J' Qi0C99iAte. COMMiAA'S: COMMEWS: 1 declare under penalty of perjury that i am a liceased tank tester in the State of California and that the information contained in this report is true and correct to the best of my knowledge. - ,_,