HomeMy WebLinkAbout2019 FMC RESULTSUNDERGROUND STORAGE TANK
MONITORING SYSTEM CERTIFICATION FORM (pase 1 of 6)
This form muat be used to document testing and serviclng of underground storage tank (UST) monitoring equipment. AaoF EihE formmust be provided to the UST owner or opeEto.. The owner or operator must submit a copy of this form to ths local agency .ogulating th€
USTS within 30 days of the date of the monltoring systom certification.
t.FACILITY INFORMATION
CERS IO Date of Monitoalng System Certification
03104t19
Business Name (San e as Facility Nafie ot DBA - Doizg Eus,ness As.)
Bakersfield City Corp Yard
Building #
Business Site Address
4101 Truxtun Avenue
City
Bakersfield
ZIP Code
93301II. UNOERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION
Name ofCompany Performing the Ce(mcation
Cal Valley Equipment
Phone #
(661) 327 - 9341 ext.
Mailing Address
7608 Fruitvale Avenue, Bakersfield, CA. 93308
Name of UST Service Technician Performing the Certification (Pflrl as sttown on the ICC CettifGation.)
Jerry Rangel
Contractor/Tank Tester License #
998733
ICC Certification #
8160834
ICC Certification Expiration Date
08124t19
Monitoring System Training and Certifications (List all apglicable ceiifications.)Expiration Date
Veeder Root 12t19
.RESULTS OF TESTING/SERVICING
lndicate and dttach the following reports if the monitoring equipment is capable of generating elther.
I Monitoring System Set-up I Alarm History Report Y N NA
Waa any monitoring equipment replaced?
(ff "Yos," identity the srycifrc devi@s eplaced and list the manufactuer and model for all Eplacenent pads in seclion lV below.)tr tr tr
Was damege, debris, or liquid found jnside any secondary containment sysiems?
(lf "Yes," descibe what was lound in section lV below.)!E n
ls all monitoring equipment operational per manufactureis specifications?
(ff "No," defidbe why in section lV below.)n M tr
tv.COMMENTS
lf directed to use this section, descibe how and when the issues werc or will be conected.
Sensor in udc 7/8 does not work.
Sensor in udc 5/6 has a cracked cable
V, CERTIFICATION BY UST SERVICE TEGHNICIAN CONDUCTING THIS TESTING
I hereby certify that the equipment identified in this document was inspected,/serviced ln accordance with California Code of
Regulations, title 23, divi3ion 3, chapter 16, section 2638 and all information contained herein is true and accurate. Attached to
this certiftcatlon is information (e-9., manufacturer8' checklisE, monitoring system set-up, alam history report, etc.) necessary
to ve fy that this information and the site Dlan showinq the layout of UST svstem ls compleb and accurate.
ice Technician Signature
zfl-/<-
CFRS = Cdifrttnia Fnuir rrl.nnel Rerr*lirr! Sv<tFrn r! = kle.ri6.ri.rn. ICC = lntemelihal Cn le C.ll rn il Y =Y*. N = N6 NA = N.* arx{hrHe
CerTification Form must be lor each monitoing system control panet.
Tank tD: 87 Unleaded
E ln-tank Gauging (Sl4/ Iark,
El Annular Space orVault Sensor
E vPH Sensor
I Mechanical LLD
n Electronic LLD
! vPH Sensor
EX Sump Sensor
E vPH sensor
fl VPH Sensor (Piping)
E Sump Sensor
E VPH Sensor (Sump)
E VPH Sensor (Piping)
E Sump Sensor
E vPH sensor
E VPH Sensor (Piping)
I Sump Sensor
n VPH Sensor (Sump)
Tank lD:
stored
E lntank Gauging (SI,? Ir
E Annular Spac€ or Vault Sensor
fl vPH Sensor
n Mechanical LLD
I Eleckonic LLD
I vPH sensor
E Sump Sensor
n VPH senso.
D VPH Sensor (Piping)
D Sump Sensor
E VPH Sensor (Sump)
E vPH sensor
D Sump Sensor
E vPH sensor
E vPH Sensor
D Sump Sensor
n VPH Sensor (Sump)
lD = l.lontifi.rli.n SW=Siilrtle.*li[E t VpH =Vi:,n,m/pni.:sr,.cHv.lrhsferic I LD E t thE hqk.tcEcr.r
Veeder Root
UNDERGROUND STORAGE TANK
MONITORING SYSTEM CERTIFICATION FORM (Pase3of 6)
lronitoring Devlce Used Device Model #ironitoring Device Used Devlce Model #
VenuTransition Sump lD:VengTransltion Sump lD:
I Sump Sensor E sump Senso.
E VPH Sensor E VPH Sensor
UoC lO: 112 UDc lD: 3/4
E Electronic Sensor 330212-001 El Electronic Sensor 330212-00'l
E Mechanical Device E Mechanical Device
D VPH Sensor n VPH Sensor
uDc lD; 5/6 UDc lD: 7/8
E Electronic Sensor 330212-OO1 X Electronic Sensor 330212-001
E Mechanical Device E Mechanical Device
E VPH Sensor E vPH Sensor
UDC ID:UDC ID:
! Eleclronic sensor ! Electronic Sensor
E Mechanical Device n Mechanical oevice
! vPH Sensor E vPH Sensor
UDC ID:UDC ID:
D Electronic Sensor fl Eleclronic Sensor
E Mechanical Device E Mechanical Device
n VPH Sensor E vPH sensor
Other Monitored Component lO:Othe. Monltored Component lD:
D Othet (Specry in section Vll.)D Othet (SN2W in &ction vll.)
Other Monitored Component lD:Other Monitored Component lD:
J Olf\et (Specify in section Vll.)I Olhet (Specify in section Vll.)
Other Monitored Component lD:Other Monitored Component lD:
A Olhet (Specify in section vtt.)D Othet (Specry in section Vll.)
lnclude info.maaion for every underground atorage tank componenl monitored by this monitorlng system control panel. lf the monitoring
syslem conlrol panel monitors morc components than this form accommodates, additlonal copies of these pages may be attached.
VII. COMMENTS
Use this section to ptovide any additional cgmmenb about the inventory of the equipment cedified.
Ir) = ldc.nifi.ri.rr \/pH =V..rr rn/Pit srrlrr/}lv.lir*Hic tlrlc=llrvh.disEnser.nrf:innre.n
CERTIFICA'
This section musl be ifa rs used to leak detection
Are the visual and audible alarms operational?
SENSOTS and breaks
Wete all sensoG at lowest point ofsecondary containment
WaS set-up reviev€d to ensure
Was lhe monjtoring panel's backup functionally tested, and confi rmed operational?
Does the flow offuelstop at the dispenser if a leak is detected in the under-dispenser containment?
containment system fails to operate or
Does the turbine automatically shut down if the piping secondary containment monitoring system detects a leak?
Which sensors initiate shut down?a that apply.) tr X Undea-dispenser containment
lf alarms are relayed to a remote monitoring station, is all communications equipment (e.9. modem) operational?
tx.
Sensor in udc 7/8 does not work.
Sensor in udc 5/6 has a cracked cable
tank gauging
Check this box if NO tank gauglng equipment is installed.(Do not complete this section.)
sec'jon must be
been and for prop€r entry and termination,
probes visually inspected for damage to ensure
Was accuracy of system's product level readings tested?
Was accuracy of system's water level readings tested?
Were all p.obes reinstalled
Were all items on the manufacturer's maintenance checklist
x.
Y = Y6 N = N^ NA = N.t A.srliEH.
U Check this box if line leak deteclors (LLD) are NOT installed. (Do not complete this section.)
fhis section must be co,nDleted if LLDS are inslalled.IA
Was a leak simulated to verify LLD perfomance?
(Check all that aDply.) Simulated leak .ate verifled:EI 3 GPH fi 0.1 GPH E 0,2 GPH tr tr tr
Was the testing apparatus properly calibrated?tr tr tr
For emergency generator tank systems, does the LLD create an audible and visual alarm when a leak is detected?tr tr a
For mechanical LLDS, does the LLD restrict the flow through the pipe when a leak is deteded?tr tr tr
For electronic LLDS, does the turbine automatically shut oif when a leak is detected?!D AI
For electronic LLDS, does the turbine automaticalty shut off if any portion of the monitoring system is disabled or disconnected?tr tr a
For electronic LLDS, does the turbane automatically shut ofi if any portion ofthe monitoring system malfunctions or fails a test?tr fI tr
For electronic LLDS, have all accessiblg wiring connections been visually inspected for kinks and breaks?n f]x
Were all items on the equipment manufaclurer's maintenance checklist completed?tr tr tr
Were all LLDS conflrmed operational within regulatory requirements?n n
For any answelof "N" above, describe in section Xlll how and whe, fhese issares were otwitl be corrected.
XIV. VACUUM / PRESSURE/ HYDROSTATIC MONITORING EOUIPMENT TESTING
tr Check this box if VPH monitoring is NOT u6ed. (Do not conptete this section.)
fhls section must be completed if VPH monltorlng is used to pe/,form leak dehction monilorlng.
System Type (Mark allthat apply.) D Vacuum E Preseure E Hydrostatic
E Pass n Fait I Pass f] rait
n Pass El rait E Pass n Fail
EI Pass n Fait n Pass E Fail
fl Pass E Fait n Pass fl Fail
E Pass n Fail L.l Pass LI l-arr
fl Pass ! Fart L_l Pass L-l Fall
E Pass I Fail E Pass E Fait
i Pass E Fail E Pass E rait
E Pass n Fait E Pass D Fail
E Pass E Fail E Pass E Fail
E Pass E Fait E Pass E Fait
I Pass D rait E Pass E Fait
How was interstitial communication verified?E Simulated leak at far ends gfthe interstitial space.
D Other (Des6rbe the method in section XV betow.)
tl Vrsual Inspection
F] Gauoe
Was the vacuum or pressure restored to operating levels in all interstitial spaces? E Yes E No (Oescrbe fre.gason in ieclion XV below.)
For any ansller of "FAIL" above, describe in section XV how and wrea arese issues were ot will be cotected.
GPH = Galklrls rEr hd 'r Y=YE& N = Nd NA = N., anrlLrhb VpH = Vad x rn P]r.sr rE ltvdryE6lc- lD: kt ntifi.ri.n
UNDERGROUND STORAGE TANK
MONITORING SYSTEM CERTIFICATION FORM lPaoesof G)
XII. LINE LEAK DETECTOR TESTING
N
XIII. COMMENTS
Sensor lD Sensor l_unctronaltv ntersttral Communication
Test
XV. COMMENTS
Monitoring System Certifi cation
UST Monitoring Site Plan
Site Address: 4101 Truxtun Avenue, Bakersfield, CA. 93301
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lnstructioos
If you already have a diagram that sho\ys all required infomation, you may include it, rather than this page, rvith your lvlonitoring
Systern Certification. On your site plan, shorv the general layout oftanks and piping. Clearly identill locations of the follolirtg
equipment, if installedi monitoring system control panels: sensors monitoring tank irnnular spaces, sumps, dispenser pans, spill
containers, or other secondary containntent areas: mechanical or electronic line leak detectors: and in-tank liquid ievel probes (if used
fbr leak detection). In the space proyided, note the date ihis Site Plan was prepared.
Page of4
Rcr. 0l/l?/08t \-016 1/l 11 1r $,Inido(s.org
' i.\ .ltl'( LiD'
Type ofAction E lnstallation Test E Repair Test I 12 Month Test
I. FACILITYINFORMATION
CERS ID Date of Spill Container Test
03t04t19
Business Name (Sane as Facility Na.ne or DBA-Doling Eusiress As./
Bakersfield City Corp
BuEiness Site Address
4101 Truxtun Avenue
City
Bakersfield
ZIP Code
93301
II. UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION
Name of UST Service Technician Performing the Test (Pnrt 6s shown on the ICC Certification-)
Jerry Rangel
Phon€ #
(661) 327 - 9341 ex.
Contractor/Tank Tester License #
998733
ICC Certification #
8160834
ICC Certification Expiration Date
08t24119
SpillContainer Testing Training and Certifications (List applbable ceftifications.)
OPW
III. SPILL CONTAINER TESTING INFORMATION
est Method Used:
E Manufaclurer Guidelines: (Spec,fy.)
E lndustry Code or Engineering Standard: (Spec,ty)
E Engineered Method: (Speciry)
Aftach the testlng procedures and all documentation required to determine the re.sul6.# ofAttached Pages
fank lO: (By tank numbeL stored product, etc.)87 Unleaded Diesel
Spjll Container Manufaclurer:OPW OPW
Method of Cathodic Protection
X Non-Metallic
E lsolation
I otter/sryify in secnon V.)
E Non-Metallic
D lsolation
E oter
(Specity in secl,.on V.)
D Non-Metallic
E lsolation
E other
(Specify in section V.)
E Non-i,Ietallic
E lsolation
D otner
(Specry in secfion V-)
lneide Diameter of SpillContainer: (/nches)11 11
Depth of Spill Container (lnches)14 12
Does the spill container have a 5 gallon capacity?EYes ENo EYes lNo EYes ENo E Yes E tto
Method to Keep Spill Container Empty
EI Drain Valve
E Onsite Pump
fl other
(Specily in section v.)
I Drain Valve
E Onsite Pump
E other
Fpecny in section V-)
E Drain Valve
E Onsite Pump
E other
(Specify in secion V-)
D Drain Valve
fl Onsite Pump
E other
(Specify in section v )
IV. SUMMARY OF TESTING RESULTS
Spill Container Test Results I Pass n Fail XI PASS L] FAII Ll Pass Ll Farr I Pass E rait
v. coMlUtENTs
A items marked "Fail" above must be explained in lhis section. Any additional comments nay also be provided here.
/I. CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS TESTING
I hereby certify that the spill containers wer6 tested in accordance with Califomia Code of Regulatione, title 23, division 3, chapter 16, section
2637.1 and all the infomation contained heroln is accu6te.
rian SignatureZ
page may
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