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HomeMy WebLinkAbout4200 ASHE RD FMC CERT 2015MONITORING 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 Marate certification or report must be prepared for each monitoringLsyste i control panel by the technician who performs the work. A copy of this fonn 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: PANAMA BUENA VISTA USD Site Address: 4200 ASHE ROAD Facility Contact Person: VICKI STALNAKER Make/Model of Monitoring System: TLS -350 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific eauipment insnected/serviced: City: BAKERSFIELD Bldg. No.: _ Zip: 93313 Contact Phone No.: ( ) Date of Testing/Servicing: 3/10/2015 Tank ID: REG87 Tank ID: DIESEL ® In Tank Gauging Probe. Model: MAG ® In -Tank Gauging Probe. Model: MAG ® Annular Space or Vault Sensor. Model: 420 0 Annular Space or Vault Sensor. Model: 420 ® Piping Sump / Trench Sensor(s). Model: 208 ® Piping Sump / Trench Sensor(s). Model: 208 ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ® Mechanical Line Leak Detector, Model: FX1 V ® Mechanical Line Leak Detector. Model: FXI DV ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ® Tank Overfill / High -Level Sensor. Model: MAG / E.O.A. ® Tank Overfill / High -Level Sensor. Model: MAGI E.O.A. ❑ Other (specify equipment type and model in Section E on Page 2). ❑ Other (specify equipment type and model in Section E on Page 2). Tank ID: WASTE OIL Tank ID: ® In -Tank Gauging Probe. Model: MAG ❑ In -Tank Gauging Probe. Model: ® Annular Space or Vault Sensor. Model: 420 ❑ Annular Space or Vault Sensor. Model: ❑ Piping Sump / Trench Sensor(s). Model: ❑ Piping Sump / Trench Sensor(s). Model: ❑ 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: NIA ❑ Tank Overfill / High -Level Sensor. Model: ❑ 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 Containment Sensor(s). Model: 208 ® Dispenser Containment Sensor(s). Model: 208 ® Shear Valve(s). ® Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) 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 reports, I have also attached a copy of the report; (check all that apply): Z System set -up Z Alarm history report Technician Name (print): BRANDON MASON Certification No.: 5284980 -UT / B34335 Signature: -' License. No.: 0611 D40 809850 Testing Company Name: RICH ENVIRONMENTAL Phone No.: (661) 392 -8687 Testing Company Address: 5643 BROOKS CT. BAKERSFIELD, CA 93308 Date of Testing/Servicing: 3/10/2015 Page 1 of 5 UN -036 —1/4 www.unidocs.org Rev. 01/17/08 Monitoring System Certification A Results of Testing/Servicing Software Version Installed: 329.01 Complete the following checklist: ® Yes ❑ No* Is the audible alarm operational? ® Yes ❑ No* Is the visual alarm operational? ® Yes ❑ 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 that other equipment will not interfere with their proper operation? ❑ Yes ❑ No* If alarms are relayed to a remote monitoring station, is all communications equipment (e.g., modem) ® N/A operational? ® 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) ® Sump /Trench Sensors; ® Dispenser Containment Sensors. Did you confirm positive shut -down due to leaks and sensor failure /disconnection? ® Yes; ❑ No. ® 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 properly? If so, at what percent of tank capacity does the alarm trigger? 90% ❑ 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. ® Yes ❑ No* Was monitoring system set -up reviewed to ensure proper settings? Attach set up reports, if applicable ® 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. E. Comments: Page 2 of 5 UN -036 — 214 www.unidocs.org Rev. 01/17/08 Monitoring System Certification F. In -Tank Gauging / SIR Equipment: bvw j ® 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: ❑ Yes ❑ No* Has all input wiring been inspected for proper entry and termination, including testing for ground faults? ❑ 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? ❑ Yes ❑ No* Were all items on the equipment manufacturer's maintenance checklist completed? * In Section H. below. describe how and when these defirienripe wore nr will hP nnrros -cad G. Line Leak Detectors (LLD): rmmnlete the fnlinwina rhprklict- ❑ 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? ❑ N/A (Check all that apply) Simulated leak rate: ® 3 g.p.h.; [10. 1 g.p.h ; ❑ 0.2 g.p.h. ® Yes ❑ No* Were all LLDs confirmed operational and accurate within regulatory requirements? ® Yes ❑ No* Was the testing apparatus properly calibrated? 0 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? ® 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 of the monitoring system malfunctions ® N/A or fails a test? ❑ Yes ❑ No* For electronic LLDs, have all accessible wiring connections been visually inspected? 0 NIA Yes ❑ No* Were all items on the equipment manufacturer's maintenance checklist completed? in 5ecuon r4 oeiow, aescrioe now ana when tnese deficiencies were or wilt be corrected. H. Comments: UN -036 -- 3/4 Page 3 of 5 www.unidocs.org Rev. 01/17/08 0Zd� . Nonitorfog System Cerfficaiian LUST Monitoring Site Plan Site Address: 4200 ASHE RD. BAKERSFIEf_Q, CA. ......................... ............... ... ............................ ........... ....................... ...........................__.. ................ ._... ............................_.. ........ I ............ AW ....................... ............................... .... .................... . ...................... . . . . . ... _......:.. ............... .............I............. -... ... ------ .... ................ ......... �..................... .. ... ..._...... ... ...... ...................... ........ 19 ig .................. .....,.................... .............. Date. ump was Raft: 418QO1 o. irastractians If you already have a diagram that shows all rcquired infoffnador� you may include it; rather than this page, with your Monitoring System certification. On your site plan, show the ge eW layout or tanks and piping. Clearly identhly locations of the rollowing equipment, if insialiech monitoring system contml panels; sensom.' monitoring tank annOw spaces, sus, dispenser pans, spill a+antaincTs,. or other secondary.contanment teas; mechanical or elecumic litre leak detwors; and i tank liquid, levcl probes (if used for leak detection). Iu the space provided, npte the date this Site Plan was.prepared. Page 6 of 5 UN-436 -4/4 w-ww.unidom- rg Rev. 01117M too-Lo- I RICHEVVIRONMENTA.L 3305 BRITTAN ST. BAKERSFIELD, CA. 93308 OFFICE (661)326-8402 FAX (661)326-8934 PRODUCT LINE LEAK DETECTOR TEST WORK SHEET W /0 #: FACILITY NAME: PANAMA BUENA VISTA USD FACILITY ADDRESS: 4200 ASHE ROAD, BAKERSFIELD,_, PRODUCT LINE TYPE: PRESSURE PRODUCT LEAK DETECTOR TYPE TEST TRIP PASS BELOW P.S.I. OR SERIAL NUMBER 3 G.P.H. FAIL UNL87 L/D TYPE: FX1V YES 10 PASS SERIAL # 1 783 DIESEL L/D TYPE: FX1DV YES 10 PASS SERIAL # 7883 L/D TYPE: PASS YES SERIAL # FAIL LID TYPE: _ PASS YES 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 ALL DATA COLLECTED IS TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE. TECHNICIAN: BRANDON MASON SIGNATURE: DATE: 3/10/15 ;,~ i S WRCB, January 200 Spill Bucket Testing Report Form This form is intended for use by contractors performing annual testing of UST spill containment structures. The completed form and printouts from tests (f applicable), should be provided to the facility owner /operator for submittal to the local regulatory agency. 1. FACILITY YNFORMATYnN Name: PANAMA BUENA VISTA USD Date of Testing: 3110115 Address: 4200 ASHE ROAD, BAKERSFIELD ffFaih Contact: VICKI ST ALNAKER Phone: Date Local Agency Was Notified of Testing: 1113115 Name of Local Agency Inspector (if present during testing): ESTER 2. TESTING CONTRACTOR TNFORMATIM Company Name: RICH ENVIRONMENTAL Technician Conducting Test: BRANDON MASON Credentials': ❑ CSLB Contractor X ICC Service Tech. ❑ SWRCB Tank Tester ❑ Other (Spec) License Number(s): 5284980 -UT 3. SPILL BUCKET TESTING INFORMATION Test Method Used: X Hydrostatic ❑ Vacuum ❑ Other Test Equipment Used: VISUAL Equipment Resolution: 0 Identify Spill Bucket (By Tank Number, Stored Product, etc. 1 REG87 FILL 2 WASTE OIL 3 DIESEL FILL 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: 12" 12" 12" Bucket Depth: 14" 14" 14" Wait time between applying vacuum/water and start of test: 30MIN 30MIN 30MIN Test Start Time (T): 1:30 1:30 1:30 Initial Reading (R): 12" 12" 12" Test End Time (TF): 2:30 2 :30 2:30 Final Reading (RF): 12" 12" 12" Test Duration (TF -- T): 60MIN 60MIN 60MIN Change in Reading (RF - Rr): 0 0 0 Pass/Fail Threshold or Criteria: 0 0 0 ut Comments — (include information on repairs made prior to testing, and recommended follow -up for failed tests) CERTIFICATION OF TECEMCL&N 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: Date: 3/10/15 ' State laws and regulations do not currently require testing to be performed by a qualified contractor. However, local requirements may be more stringent. SOFTWAk E REVISIOWLEVEL VERSION 829.01 SOFTWARE;t 346329-100-B ,-CREATED - 09-01-29.15.44 NO SOFTWARE MODULE SYSTEM FEATURES: PERIODIC IN-TANK TESTS ANNUAL IN-TANK TESTS SYSTEM SETUP MAR 10.- 2015 2:15 PM -.,SYSTEM UNITS ..W.S. SYSTEM LANGUAGE . ENGLISH. SYSTEM DATE/TIME FORMAT MON DD YYYY HH:MM:SS xM PANAMA BUENA VISTA 4200 ASHE RD BAKERSFIELD CA s. v `H Z TI IFT .,ME­'j'',.-*' 1 -'00 AM S'IFT T ME,f` ; DISABLED SHIFT TIME : DISABLED SHIFT TIME-'4 : DISABLED TANK PER-`-.TST NEEDED WRN DISABLED TANK ANN TST NEEDED WRN DISABLED LINE RE-ENABLE METHOD PASS LINE TEST X ,INE PER TST NEEDED WRN /'DISABLED LINE ANN TST NEEDED WRN DISABLED PRINT TC VOLUMES ENABLED TEMP COMPENSATION VALUE (DEC F ): 60.0 STICK HEIGHT OFFSET DISABLED ULLAGE: 90% H-PROTOCOL DATA FORMAT HEIGHT DAYLIGHT SAVING TIME ENABLED START DATE MAR WEEK 2 SUN START TIME 2:00 AM END DATE NOV WEEK I SUN END TIME 2:00 AM PE-DIRECT LOCAL PRINTOUT DISABLED EURO PROTOCOL PREFIX S SYSTEM SECURITY CODE : 000000 MAINTENANCE HISTORY DISABLED TANK CHART SECURITY DISABLED ` CUSTOM ALARMS DISABLED SERVICE NOTICE DISABLED ISO 3166 COUNTRY CODE: MASS/DENSITY DISABLED COMMUNICATIONS SETUP - - - - - - - - - - - - - PORT SETTINGS: COMM BOARD : 5 (RS-485) BAUD RATE : 2400 PARITY : EVEN STOP BIT : I STOP DATA'LENGTH: 7 DATA RS-232 SECURITY CODE : DISABLED COMM BOARD : 6 (RS-232) BAUD RATE : 1200 PARITY : ODD STOP BIT : I STOP DATA LENGTH: 7 DATA RS-232 SECURITY CODE : DISABLED FLOAT SIZE: WATER WARNING HIGH WATER LIMIT.: MAX OR LABEL VOL: OVERFILL LIMIT v HIGH PRODUCT DELIVERY-LIMIT 4.0 IN. LOW PRODUCT - LEAK ALARM LIMIT: SUDDEN LOSS LIMIT:' TANK TILT PROBE OFFSET 2.0 3.0 12153 90% 10937 95% 11545 10% 1215 1000 50 50 1.25 0.00 SIPHON MANIFOLDED TANKS T#: NONE LINE MANIFOLDED TANKS T#: NONE LEAK MIN PERIODIC: 33% 4010 LEAK MIN ANNUAL 50%, • 6076 PERIODIC TEST TYPE STANDARD ANNUAL TEST FAIL ALARM DISABLED PERIODIC TEST FAIL ALARM DISABLED GROSS TEST FAIL ALARM DISABLED ANN TEST AVERAGING: OFF PER TEST AVERAGING: OFF TAW TEST NOTIFY: 'OFF TNk TST SIPHON BREAK.,OFp DELIVERY DELAY IN -TANK SETUP T 2:UNLEADED PRODUCT CODE THERMAL COEFF 2 o00700 TANK DIAMETER 95.00 TANK PROFILE 20 PTS FULL VOL 90-3 INCH VOL 12153 11928 85-5 INCH VOL 11520 80-8 INCH VOL 76.0 INCH VOL 11016 71.2 INCH VOL 10423 9770 66.5 INCH VOL 61-7 INCH VOL 9087 57.0 INCH-VOL 8355 7614 52.2 INCH VOL 61941 47.5 INCH VOL 6076 42.7 INCH VOL 5,295 38.0 INCH VOL :33.2 INCH VOL 4539 28.5 INCH VOL 3782 3066 23.7 INCH VOL 2368 19-0 INCH VOL 1730 14.2 INCH VOL : 1136 9-5 INCH VOL : 632 4.7 INCH- VOL : 224 FLOAT SIZE: WATER WARNING HIGH WATER LIMIT.: MAX OR LABEL VOL: OVERFILL LIMIT v HIGH PRODUCT DELIVERY-LIMIT 4.0 IN. LOW PRODUCT - LEAK ALARM LIMIT: SUDDEN LOSS LIMIT:' TANK TILT PROBE OFFSET 2.0 3.0 12153 90% 10937 95% 11545 10% 1215 1000 50 50 1.25 0.00 SIPHON MANIFOLDED TANKS T#: NONE LINE MANIFOLDED TANKS T#: NONE LEAK MIN PERIODIC: 33% 4010 LEAK MIN ANNUAL 50%, • 6076 PERIODIC TEST TYPE STANDARD ANNUAL TEST FAIL ALARM DISABLED PERIODIC TEST FAIL ALARM DISABLED GROSS TEST FAIL ALARM DISABLED ANN TEST AVERAGING: OFF PER TEST AVERAGING: OFF TAW TEST NOTIFY: 'OFF TNk TST SIPHON BREAK.,OFp DELIVERY DELAY LEAK TEST METHOD TEST ON DATE :. ALL TANK JAN 29, 2009 START,TIME : DISABLED TEST RATE :0.20 GAL/HR DURATION 2 HOURS TST EARLY STOP:DISABLED LEAK TEST REPORT FORMAT NORMAL LIQUID SENSOR SETUP - - - - - - - - - - - - L I:UNLEADED ANNULAR TRI-STATE (SINGLE FLOAT) CATEGORY : ANNULAR SPACE L 2:UNLEADED STP SUMP TRI-STATE (SINGLE FLOAT) CATEGORY : STP SUMP L 3:DIESEL ANNULAR TRI-STATE (SINGLE FLOAT) CATEGORY : ANNULAR SPACE L 4.:DIESEL STP SUMP TRI-STATE (SINGLE FLOAT) i CATEGORY : STP SUMP L 5:DISPENSER 1-2 TRI-STATE (SINGLE FLOAT) CATEGORY DISPENSER PAN L 6:DISPENSER 3-4 TRI-STATE (SINGLE FLOAT) CATEGORY : DISPENSER PAN L 7:WASTE OIL TRI-STATE (SINGLE FLOAT) CATEGORY OTHER SENSORS ­­0U'TPUT* RELAY SETUP - - - - - - - - - - - - R I:UNLEADED SHUTDOWN TYPE: STANDARD NORMALLY CLOSED FILAXI'l H l,'j*j"0XY RE9()Kj- ----- SENSOR ALARM - - - -- L I:UNLEADED ANNULAR ANNULAR SPACE SENSOR OUT ALARM MAR 10. 2015 1:32 PM SMARTSENSOR SETUP - - - - - - - - - - - - s I : CCVP CATEGORY VAPOR VALVE 5 2:PRESSURE SENSOR CATEGORY VAPOR PRESSURE 5 S:ATM CATEGORY ATM P SENSOR ENDUE ALARM HISTORY REPORT ----- SENSOR ALARM ____- L 3:DIESEL ANNULAR ANNULAR SPACE SENSOR OUT ALARM MAR 10, 2015 1:32 PM FUEL ALARM MAR 10, 2015 1:27 PM SETUP DATA WARNING JAN 29. 2009 8:05 AM FUEL ALARM IN-TANK ALARMS MAR 10, 2015 1:26 PH T 2:HlGk WATER ALARM SETUP DATA WARNING T 2:LOW PRODUCT ALARM JAN 29, 2009 8:05 AM LIQUID SENSOR ALMS L 2:FUEL ALARM L 6:FUEL ALARM L 2:SHORT ALARM L 6:SHORT ALARM PMC ALARMS VP EMISSIONS FAIL VP PRESSURE FAIL VP DUTY CYCLE FAIL END PMC SENSOR FAULT R 3:DIESEL SHUTDOWN TYPE: STANDARD NORMALLY CLOSED IN-TANK ALARMS T I:HIGH-WATER ALARM T I:LOW PRODUCT ALARM ALARM HISTORY REPORT LIQUID SENSOR ALMS L 4:FUEL ALARM SENSOR ALARM L 5:FUEL ALARM L 2:UNLEADED STP SUMP 4:SHORT ALARM STP SUMP L 5:SHORT ALARM SENSOR OUT ALARM MAR 10, 2015 1:32 PM R 4:WASTE OIL TYPE: I FUEL ALARM STANDARD MAR 10. 2015 1:25 PM NORMALLY CLOSED SETUP DATA WARNING NOV IS. 2014 11:01 AM I N-TANK'ALARMS ALL:OVERFILL ALARM ALL:HIGH PRODUCT ALARM ALL:MAX PRODUCT ALARM SMARTSENSOR SETUP - - - - - - - - - - - - s I : CCVP CATEGORY VAPOR VALVE 5 2:PRESSURE SENSOR CATEGORY VAPOR PRESSURE 5 S:ATM CATEGORY ATM P SENSOR ENDUE ALARM HISTORY REPORT ----- SENSOR ALARM ____- L 3:DIESEL ANNULAR ANNULAR SPACE SENSOR OUT ALARM MAR 10, 2015 1:32 PM FUEL ALARM MAR 10, 2015 1:27 PM SETUP DATA WARNING JAN 29. 2009 8:05 AM ALARM HISTORY REPORT ----- SENSOR ALARM L 4:DIESEL STP SUMP STIR SUMP SENSOR OUT ALARM MAR 10. 2015 1:32 PM FUEL ALARM MAR 10, 2015 1:30 pm SETUP DpkTA WARNING NOV IS- 2014 11:04'AM x x x x X END x 'x x * x ALARM HISTORY REPORT ----- SENSOR ALARM - - ---- L 5:DISPENSER 1-2 DISPENSER PAN SENSOR OUT ALARM MAR 10,*2015 1:32 PM FUEL ALARM MAR 10. 2015 1:29 PM SETUP DATA WARNING JAN 29, 2009 8:05 AM END ALARM HISTORY REPORT SENSOR ALARM - - - -- L 6:DISPENSER 3-4 DISPENSER PAN SENSOR OUT ALARM MAR 10, 2015 1:32 PM' FUEL ALARM MAR 10. 2015 1;27 PM SETUP DATA WARNING JAN Pq- onno 0 • n= Ah., SENSop, ALARM L 7-WASTE OIL OTHER SENSOR'S pUE AM MAR L 10 LAR, 2015 2 :15 PM I SENSOR OUT ALARM s I t 32 PM, MAR 10, 2015 SETUP' DATA WARN114G AM JAN 29, 2009 * A X -* x END X A X x X ALARM HisroRy REPORT SEN90p, ALARM OTHER SENSORS END MONITOR CERT. FAILURE REPORT SITE NAW : PANAMA BUENA VISTA USD DATE: 3110115 ADDRESS: 4200 ASHE ROAD TECHNICIAN: BRANDON MASON CITY: BAKERSHELD SIGNATURE: THE FOLLOWING COMPONENTS WERE REPLACED/REPAIRED 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 ENVIRONMANTAL 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.