Loading...
HomeMy WebLinkAbout3711 MT. VERNON AVENUE (2)MONIT01UNG SYSTEM CERTIFICATION F'or Use By All Jurisdictions Within the State of California V Authority Cited: Chapter 6 7, Health andSafety Code; Chapte. 16, Division 3, Title 23, California Code of Regulations This form must he used to document testing and servicing of monitoring equipment. A separate certification or report must be prepared forggeb 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 (o the local agency regulating UST systems within 34 days oftest date. A. General information Facility Name: HUNGRY'S MARKET Bldg. No.: Site Address: 3711 MT VERNON AVENUE City: BAKERSFIELD.. Zip: 93306 Facility Contact Person: Contact Phone No.: ( L Make /Model of Monitoring System: INCON _ Date of Testing/Servicing: 9/1/2011 B. Inventory of Equipment 'rested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced: Tank ID: UNLEADED 87 rank W PREMIUM 91 In -Tank Gauging Probe. Model: INCON Vj In -Tank Gauging Probe. Model: INCON Q Annular Space or Vault Sensor. Model: C Annular Space or Vault Sensor. Model: 0 Piping Sump /Trench Sensor(s). Model: LS -3 ED Piping Sump 1 Trench Sensor(s) . Model: LS-3 Fill Sump Scnsor(s). Model: Fill Sump Sensor(s). Model: Mechanical Line Leak Detector. Model: RED JACKET Mechanical Line Leak Detector, Model: RED JACKET Electronic Line Leak Detector. Model: Electronic.We Leak Detector. Model: Tank Overfill / High -Level Sensor. Model: 0 Tank Overfill / High -Level Sensor. Model: Q Other (speciA, equipment type and model in Section $ on Page 2). Q Other (specifv equipment type and model in Section E on Page 2). rank it): DIESEL 7link ID: In -Tank Gauging Probe. Model: INCON In -Tank Gauging Probe. Model: Annular Space or Vault Sensor. Model: Q Annular Space or Vault Sensor. Model: Piping Sump / Trench Sensor(s). Model: LS -3 Q Piping Sump I Trench Sensor(s). Model: Q Fill Sump Sensor(s). Model: Q Fill Sump Sensor(s). Model: Mechanical Line Leak Detector. Model: RED JACKET Q Mechanical Line Leak Detector. Model: Q Electronic Line leak Detector. Model: Q Electronic Line Leak Detector. Model: Tank Overfill / High -Level Sensor. Model: Q Tank Overfrll/ High -Level Sensor. Modes: 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: 112 Dispenser ID: 314 Dispenser C=ontainment Sensor(s). Model: LS-3 Dispenser Cor.itainment Sensor(s). Model: LSw3 Shear Valve(s). Shear Valve(s). Q Dispenser Containment Float(s) and Chain(s): j'Dispeoser Containment Float(s) and Chain(s). Dispenser ID: Dispenser ID: Q Dispenser C=ontainment Sensor(s). Model: Dispenser Containment Sensor(s). Model: Shear Valve(S). Q Shear Valve(s). Dispenser Containment Float(s) and Chain(s). Dispenser Containment Float(s) and Chain(s). E Dispenser ID: Dispenser ID: Dispenser Containment Sensor(s). Model: Q Dispenser Containment Sensor(s). Mcdcl: Q Shear Valve(s). Shear VaNe(s). Dispenser Containment Float(s) and Chain(s). Dispenser Containment Float(s) and Chain(s). If the facility contains more tanks ordispensers, copy this forma Include information for every tank and dispenser at the iacility. C. Certification - 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) necessa to verify that this information is correct and a.Plot Plan showing the layout of monitoring equipment. For any equt went capabl generating such reports, I have also attached a copy of the report; (check all that apply): ®.System set -up A.larin ory report Technician Name (print): RICH PHILLIPS Signature: Certification No.: A2908411035169 -UT License. No.: C611 D40 809850_ Testing Company Name: RICH ENVIRONMENTAL Phone No.: (661) 3264$402 Testing Company Address: 5643 BROOKS CT, BAKERSPIELD, CA. 93308 Date of Testing /Servicing: 9/1/2011 Page 1 of 5 UN -036— 1/4 www.unidocs.org Rev. 01 /17/08+ Monitoring System Certification D. Results. of Testing/Servicing Software Version Installed: Comnlete the followinu checklist: q1_?Z111b1 r Yes No* Is the audible. alarm operational? Yes No* is the visual alarm operational? Yes D 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 thatother equipment will not interfere with their proper operation? Q Yes No* If alarms are . relayed to a remote monitoring station, is all communications equipment (e.g., modem) lD N/A operational? Yes q No* for pressurized piping systems, does the turbine automatically shutdown 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? ® Yes; Q No. Yes No* For tank systems that utilize the monitoring system as the primary tank overfill warning device (i.e., no Z 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, atwhat pereent 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 F, below. Yes* E@ 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 setup reports, if applicable Yes No* Is all monitoring equipment operational per manufacturer's specifications? I In Section E below, describe how and when these deficiencies were or will be corrected. E. CoMmeuts: Page 2 of 5 LN -036 — 2/4 www:unidm.org Rev. 01/17/08 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 p No* Has all input wiring been inspected for.proper entry and termination, including testing for.ground faults? Yes p 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? 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_ G. Line Leak Detectors (LLD}: 'Check this box ifLLDs are not installed. Cornulete the followinv checklist: 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.; E10.1. g.p.h ; [10.2 g.p.h. ties No* Were all LLDs confirmed operational and accurate within regulatory requirements? . 0 Yes No* Was the testing apparatus properly calibrated? Yes No* . For mechanical,LLDs,. does the LLD restrict product flow if.it detects a leak? N/A p Yes 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 N/A or disconnected? Yes No* For electronic LLDs, does the turbine automatically shut off if any portion ofthe monitoring system malfunctions N/A orfails a test? Yes No* For electronic LLDs, have all accessible wiring connections been visually inspected? ED 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-036 - 3/4 Page 3 of 5 w%tiv.gnidocs.org Rev. 01/17/08 L-1335 Monitoring System Certification UST Monitoring Site ]Plan Site Address: 3D u LA mE)RN(,N A `iv-_ Date map was drawn:! Instructions Lk R 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. Page 5 of 5 W -036 — 4/4 www.unidGm.org Rev. 01117108 7 X335'1 SWRCB, January 2006 Spill Becket 'Vesting Report dorm Thisform is intendedfor use by contractors performing annual testing of USTspill containment structures. The completedform and printoutsfrom tests (ifapplicable), should be provided to-thefacility owner /operatorfor"submittal to the local regulatory agency. 1. FACILITY INFORMATION Facility Name: HUNGRY'S MARKET Date of Testing: 9/1/_11 Facility Address: 3711 NIT VERNON AVENUE, BAKERSFIELD Facility Contact: Phone: Date Local Agency Was Notified of Testing: 8/2/11 Name of Local Agency - Inspector (fpresent during testing): 2. TESTING CONTRACTOR IN—FORMATION Company Name: RICH ENVIRONMENTAL Technician Conducting Test. RICH.PHILL'IPS Credentialsl: E; CSLB Contractor X ICC Service Tech. b SWRCB Tank Tester 0 Other (Specify) License Number(s): 1035169 -UT 3. SPILL BUCIET TESTING INFORMATION Test Method Used: X Hydrostatic p Vacuum Other . Test Equipment Used: VISUAL Equipment Resolution: 0 Identify Spill Bucket (By Tank Number, Stored Product, etc. 1 REG 87 -FILL 2 PREM 91 -FILL 3 DIESEL FILL 4 Bucket Installation Type: X Direct Bury D Contained, in Sump. X Direct Bury D Contained in Sump X Direct Bury . 0 Contained in Sump" C Direct Bury D Contained in Sum Bucket Diameter: , IT' 12" 12" Bucket Depth: 14" 14" 14" Wait time between applying vacuum /water and start of test:. 30 MIN 30 MIN 30 MIN Test Start Time (Ti): 9:00 9:00 9:00 Initial Reading (Rj): 14" 14" 14" Test End -Time (TF): 10:00 10:00 10:00 Final Reading (RF): 14" 14" 14" rest Duration (TF — TO: 1 -14OUR I -HOUR w 1 -HOUR Change in Reading (RF - Rl): 000 :. 000 " 000 Pass /Fail Threshold or Criteria: 0.00 0.00 l- 0.00 Test :Result .. ' f.. Comments — (include information on repairs made prior to testing, andrecommendedfollow -upforfailed tests) CERTIFICATION OF TECHNICL&N RESPONSIBLE FOR CONDUCTING THIS TESTING I hereby.certto that all the information cons din this report is true, accurate, and infull compliance with legal requirements. Technician's Signature: Date: 9/1/11 State laws and regulations do not currently require testing to be performed by a qualified contractor. However; local requirements may be more stringent. 4: 1 - RICH ENVIRO.MENTAL 3305 BRITTAN ST'. BAKERSFIELD, CA. 93308 OFFICE.(661)326-8402 FAX (661)326 -9934 PRODUCT LINE LEAK D9TECTOR TEST WORK SHEET W/0#: FACILITY NAME: HITNG.RVS ''MARKET FACILITY ADDRESS: 3711 MT VERNON AVENUE, BAKERFIELD PRODUCT LINE TYPE: PRESSURE PRODUCT LEAK DETECTOR 'TYPE. PEST TRIP PASS BELOW P.S.I. OR SERIAL NUMBER G.P.I. FAIL IJNL87 L/D TYPE: RED JACKET 10 PASS YES SERIAL # MECHANICAL . PRENI91 LID TYPE : RED JACKET 10 PASS YES SERIAL # MECHANICAL DIESEL L/D TYPE : RED JACKET 11 PASS , YES SERIAL # .MECHANICAL. L/D TYPE: PASS YES I SERIAL # FAIL 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 ALI, UATA COLLECTED IS TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE. TECHNICIAN: RICH PRILL SIGNATURE: DATE: 9/1/11 2: C L--7 :;K: -13 1) -Q 3 x, il> x .u Z' T, -D, 'D Ar i:. .11 C) J 4 !12 J> K, j. j", R: 1-7) D ca c-- --I Q z ;z C;) c) Tj .-i -.1 D z Q 2z. 1 1 *7 -F" 'T' 1 JC:,'; n'. ' Am ,IM 'KI f -11 r Aj Z r C i at? L 77 F-. -K71f- -A -C CD "3 0 --4 A 17- V U) '(1 '6 rr) C' -':t 'Z' I- Tj TI 1-" f • " \ 11 11 'P 11Tto ;,I AL T) 0 --DXi 0 •) 1 4 -M Z 12: 2: 6 x) fn ci Ll -I o im -11 —!1 ts) "\' 11 -A -A 7- IS) In m c X-) 2! QDt' LnI'll IV 11 1 W LID 1 4 rA r" I rq e- 'm r-' jmo' "Ir, • D 0 -u 'TJ ;Qi;u ZC -M, -C 17, -A oUD --o -,-# 'n,.—o Cii -Ly I t-1, RL) -3t DItTjFqd. F01 -7ei Q ;7 m Ti 35fa1 - ;K - I 'I .,Q it -,I W ril P1fr- F, Tj J- i try R ITI C-7 all I A"i 0) Tj -QFri I-q 0 Y., l W A wf rf Y D 73> 4D PI I 13 1'a _j I R J, 2: C L--7 :;K: -13 1) -Q 3 x, il> x .u Z' T, -D, 'D Ar i:. .11 C) J 4 !12 J> K, j. j", R: 1-7) D ca c-- --I Q z ;z C;) c) Tj .-i -.1 D z Q 2z. 1 1 *7 -F" 'T' 1 JC:,'; n'. ' Am ,IM 'KI f -11 r Aj Z r C i at? L 77 F-. -K71f- -A -C CD "3 0 --4 A 17- V U) '(1 '6 rr) C' -':t 'Z' I- Tj TI 1-" f • " \ 11 11 'P 11Tto ;,I AL T) 0 --DXi 0 •) 1 4 -M Z 12: 2: 6 x) fn ci Ll -I o im -11 —!1 ts) "\' 11 -A -A 7- IS) In m c X-) 2! QDt' LnI'll IV 11 1 W LID 1 4 rA r" I rq e- 'm r-' jmo' "Ir, • D 0 -u 'TJ ;Qi;u ZC -M, -C 17, -A oUD --o -,-# 'n,.—o Cii -Ly I t-1, RL) -3t DItTjFqd. F01 -7ei Q ;7 m Ti 35fa1 - ;K - I 'I .,Q it -,I W ril P1fr- F, Tj J- i try R ITI C-7 all I A"i 0) Tj -QFri I-q 0 p -o "n u, i;, L, 1, p a, 7;1 T? x -1d __D A., -V u At -Ij :jj J." 7. r> :P D 7, 3 -1 T D I I Q 70 -4 n In J) C Lo _0 v :6 -.I> in i'l V'- !h A T" -A A!,-) ID cc, "0 01 4 :o . q l-.) pi, -a Z 'T 4 4 1 D 11'.11 711 It Tj k::: a D ',D {4 jzA "-.,j _z: ci 7A z 1 %uIC, 70 aTj 1.o zf 03 J.. r-j ;D -C ft F A> :D. i. 711 C_ T, 7A is l--' D ;Jf 171 L) z 'n rj -z'. -TI zi _,Z: 11 C, Q n it 71 c 71 T) 17. rt X1 F o'4 m., 4 Cf l'T , ev Uj C. U, Ci CY ox J C.". ff. F 21 C Y. a IP_ l: r Ir n 81 4f.; yis'., 4.. J t b 1.0 . L- C-1 c5 n IN- LO r A _j IT- 4T- r fj ul 1r, U, S, j/ j _j X, 7,4 I n CV S: I- C:z S71 cf. C afure LL I-- cx fx cX' Id: 'r. rt-, L,&: re feUJF- a. 1, 1 6 uOf rx U! t-1 U.! w 111 Ce X CJ f - C, I- C, C-j n- (f+ L11 C. CI C, a: U-) u- JD- a- aDCD Q- v 47 fl- Z z i.-., 1E z I c 77- o'4 m., 4 Ci CY C.". ff. fl a n yis'., 4.. J t b 1.0 . L- C-1 c5 ni 'r. Lo L, .,z ui7j -jz. r A _j IT- 4T- A f ul 1r, U, S, cf-, 'ID j _j X, 7,4 I n CV S: I- C:z cf. C afure LL I-- cx fx cX' Id: 'r. rt-, L,&: r e feUJF- a. 1, 1 6 uOf rx U! t-1 U.! w 111 Ce X CJ f - C, I- C, C-j n- (f+ L 11 C. CI C, a: U-) u- JD- a- aDCD Q- v 47 fl- Z z i.-., 1E z I c 77- T - r'- IcCN - cc, c:. V. is cl, Ul I LLY rt C,j N I, cel U) C!2 4T, er, of rif 2: :r :F, t lZ 0 hc CL CL p'' t1:: r; Cl t" SITE . NAME: HUNGR 'S MARKET DATE: 9/1/11 THE FOLLOWING COMPONENTS WERUREPLACED/REPAIREID TO COMPLETE TESTING. REPAIRS: NONE LABOR NONE PARTS INSTALLED: NONE NAME: 'TITLE .: . SIGNATURE THE ABOVE NAMED PERSON TAKES FULL RESPONSIBILITY OF NOTIFYING THE APPROPRIATE PARTY TO HAVE CORRECTIVE ACTION. TAKEN TO REPAIR THE ABOVE LISTED PROBLEMS AND NOTIFYING RICH ENV[RONMANTAL 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.