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HomeMy WebLinkAboutFMC 2019CERS = California Environmental Reporting System, ID = Identification, ICC = International Code Council, Y = Yes, N = No, NA = Not applicable UNDERGROUND STORAGE TANK MONITORING SYSTEM CERTIFICATION FORM (Page 1 of 6) This form must be used to document testing and servicing of underground storage tank (UST) monitoring equipment. A copy of this form must be provided to the UST owner or operator. The owner or operator must submit a copy of this form to the local agency regulating the USTs within 30 days of the date of the monitoring system certification. I. FACILITY INFORMATION CERS ID 10132183 Date of Monitoring System Certification 8/13/2019 Business Name (Same as Facility Name or DBA – Doing Business As.) Gasko Food Mart Building # Business Site Address 430 East California Ave City Bakersfield ZIP Code 93306 II. UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION Name of Company Performing the Certification Advanced Compliance Phone # (661) 706 - 4321 Ext. Mailing Address 3704 Littlefalls Ct Bakersfield, Ca. 93312 Name of UST Service Technician Performing the Certification (Print as shown on the ICC Certification.) Bradley Hinsley Contractor/Tank Tester License # 971259 ICC Certification # 8373948 ICC Certification Expiration Date 8/23/2019 Monitoring System Training and Certifications (List all applicable certifications.) Expiration Date ICC Service Techican 8/10/2021 Veeder-root 2/8/2020 Redjacket LLD 5/23/2021 VMI 1/18/2020 III. RESULTS OF TESTING/SERVICING Indicate and attach the following reports if the monitoring equipment is capable of generating either. Y N NA Monitoring System Set-up Alarm History Report Was any monitoring equipment replaced? (If “Yes,” identify the specific devices replaced and list the manufacturer and model for all replacement parts in section IV below.) Was damage, debris, or liquid found inside any secondary containment systems? (If “Yes,” describe what was found in section IV below.) Is all monitoring equipment operational per manufacturer’s specifications? (If “No,” describe why in section IV below.) IV. COMMENTS If directed to use this section, describe how and when the issues were or will be corrected. V. CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS TESTING I hereby certify that the equipment identified in this document was inspected/serviced in accordance with California Code of Regulations, title 23, division 3, chapter 16, section 2638 and all information contained herein is true and accurate. Attached to this certification is information (e.g., manufacturers' checklists, monitoring system set-up, alarm history report, etc.) necessary to verify that this information and the site plan showing the layout of UST system is complete and accurate. UST Service Technician Signature ID = Identification, SW = Single-walled, VPH = Vacuum/Pressure/Hydrostatic, LLD = Line leak detector UNDERGROUND STORAGE TANK MONITORING SYSTEM CERTIFICATION FORM (Page 2 of 6) VI. INVENTORY OF EQUIPMENT CERTIFIED A separate Monitoring System Certification Form must be prepared for each monitoring system control panel. Make of Monitoring System Control Panel Veeder-Root Model of Monitoring System Control Panel TLS-350 Software Version Installed 335.00 Check the appropriate boxes to indicate specific equipment inspected/serviced. Monitoring Device Used Device Model # Monitoring Device Used Device Model # Tank ID: 87 (By tank number, stored product, etc.) Tank ID: 91 (By tank number, stored product, etc.) In-tank Gauging (SW Tank) MAG In-tank Gauging (SW Tank) MAG Annular Space or Vault Sensor 794390-420 Annular Space or Vault Sensor 794390-420 VPH Sensor VPH Sensor Product Piping Product Piping Mechanical LLD 99 LD-2000 Mechanical LLD FX-1V Electronic LLD Electronic LLD VPH Sensor (Piping) VPH Sensor (Piping) Sump Sensor 794380-208 Sump Sensor 794380-208 VPH Sensor (Sump) VPH Sensor (Sump) Fill Piping Fill Piping VPH Sensor (Piping) VPH Sensor (Piping) Sump Sensor 794380-208 Sump Sensor 794380-208 VPH Sensor (Sump) VPH Sensor (Sump) Vent Piping Vent Piping VPH Sensor (Piping) VPH Sensor (Piping) Sump Sensor Sump Sensor VPH Sensor (Sump) VPH Sensor (Sump) Vapor Recovery Piping Vapor Recovery Piping VPH Sensor (Piping) VPH Sensor (Piping) Sump Sensor Sump Sensor VPH Sensor (Sump) VPH Sensor (Sump) Monitoring Device Used Device Model # Monitoring Device Used Device Model # Tank ID: (By tank number, stored product, etc.) Tank ID: (By tank number, stored product, etc.) In-tank Gauging (SW Tank) In-tank Gauging (SW Tank) Annular Space or Vault Sensor Annular Space or Vault Sensor VPH Sensor VPH Sensor Product Piping Product Piping Mechanical LLD Mechanical LLD Electronic LLD Electronic LLD VPH Sensor (Piping) VPH Sensor (Piping) Sump Sensor Sump Sensor VPH Sensor (Sump) VPH Sensor (Sump) Fill Piping Fill Piping VPH Sensor (Piping) VPH Sensor (Piping) Sump Sensor Sump Sensor VPH Sensor (Sump) VPH Sensor (Sump) Vent Piping Vent Piping VPH Sensor (Piping) VPH Sensor (Piping) Sump Sensor Sump Sensor VPH Sensor (Sump) VPH Sensor (Sump) Vapor Recovery Piping Vapor Recovery Piping VPH Sensor (Piping) VPH Sensor (Piping) Sump Sensor Sump Sensor VPH Sensor (Sump) VPH Sensor (Sump) ID = Identification, VPH = Vacuum/Pressure/Hydrostatic, UDC = Under-dispenser containment UNDERGROUND STORAGE TANK MONITORING SYSTEM CERTIFICATION FORM (Page 3 of 6) Monitoring Device Used Device Model # Monitoring Device Used Device Model # Vent/Transition Sump ID: Vent Pan Vent/Transition Sump ID: Sump Sensor 794380-208 Sump Sensor VPH Sensor VPH Sensor UDC ID: 1/2 UDC ID: 3/4 Electronic Sensor 794380-208 Electronic Sensor 794380-208 Mechanical Device Shear Valve Mechanical Device Shear Valve VPH Sensor VPH Sensor UDC ID: 5/6 UDC ID: Electronic Sensor 794380-208 Electronic Sensor Mechanical Device Shear Valve Mechanical Device VPH Sensor VPH Sensor UDC ID: UDC ID: Electronic Sensor Electronic Sensor Mechanical Device Mechanical Device VPH Sensor VPH Sensor UDC ID: UDC ID: Electronic Sensor Electronic Sensor Mechanical Device Mechanical Device VPH Sensor VPH Sensor Other Monitored Component ID: Other Monitored Component ID: Other (Specify in section VII.) Other (Specify in section VII.) Other Monitored Component ID: Other Monitored Component ID: Other (Specify in section VII.) Other (Specify in section VII.) Other Monitored Component ID: Other Monitored Component ID: Other (Specify in section VII.) Other (Specify in section VII.) Include information for every underground storage tank component monitored by this monitoring system control panel. If the monitoring system control panel monitors more components than this form accommodates, additional copies of these pages may be attached. VII. COMMENTS Use this section to provide any additional comments about the inventory of the equipment certified. Y = Yes, N = No, NA = Not Applicable UNDERGROUND STORAGE TANK MONITORING SYSTEM CERTIFICATION FORM (Page 4 of 6) VIII. MONITORING SYSTEM AND PROGRAMMING This section must be completed if a monitoring panel is used to perform leak detection monitoring. Y N NA Are the visual and audible alarms operational? Were all sensors visually inspected for kinks and breaks in the cables and for residual buildup to ensure that floats move freely, functionally tested, and confirmed operational? Were all sensors installed at lowest point of secondary containment and positioned so that other equipment will not interfere with their proper operation? Was monitoring system set-up reviewed to ensure proper settings? Was the monitoring panel’s backup battery visually inspected, functionally tested, and confirmed operational? Does the flow of fuel stop at the dispenser if a leak is detected in the under-dispenser containment? Does the turbine automatically shut down if the piping secondary containment monitoring system fails to operate or is electrically disconnected? Does the turbine automatically shut down if the piping secondary containment monitoring system detects a leak? Which sensors initiate positive shut down? (Check all that apply.) Sump Under-dispenser containment If alarms are relayed to a remote monitoring station, is all communications equipment (e.g. modem) operational? For any answer of “N” above, describe in section IX how and when these deficiencies were or will be corrected. IX. COMMENTS X. IN-TANK GAUGING TESTING Check this box if tank gauging is used only for inventory control. (Do not complete this section.) Y N NA Check this box if NO tank gauging equipment is installed. (Do not complete this section.) This section must be completed if in-tank gauging is used to perform leak detection monitoring. Has all input wiring been inspected for kinks and breaks in the cables and for proper entry and termination, including testing for ground faults? Were all in-tank gauging probes visually inspected for damage and residue buildup to ensure that floats move freely, functionally tested, and confirmed operational? Was accuracy of system’s product level readings tested? Was accuracy of system’s water level readings tested? Were all probes reinstalled properly? Were all items on the equipment manufacturer’s maintenance checklist completed? For any answer of “N” above, describe in section XI how and when these deficiencies were or will be corrected. XI. COMMENTS GPH = Gallons per hour, Y = Yes, N = No, NA = Not applicable, VPH = Vacuum/Pressure/Hydrostatic, ID = Identification UNDERGROUND STORAGE TANK MONITORING SYSTEM CERTIFICATION FORM (Page 5 of 6) XII. LINE LEAK DETECTOR TESTING Check this box if line leak detectors (LLD) are NOT installed. (Do not complete this section.) Y N NA This section must be completed if LLDs are installed. Was a leak simulated to verify LLD performance? (Check all that apply.) Simulated leak rate verified: 3 GPH 0.1 GPH 0.2 GPH Was the testing apparatus properly calibrated? For emergency generator tank systems, does the LLD create an audible and visual alarm when a leak is detected? For mechanical LLDs, does the LLD restrict the flow through the pipe when a leak is detected? For electronic LLDs, does the turbine automatically shut off when a leak is detected? For electronic LLDs, does the turbine automatically shut off if any portion of the monitoring system is disabled or disconnected? For electronic LLDs, does the turbine automatically shut off if any portion of the monitoring system malfunctions or fails a test? For electronic LLDs, have all accessible wiring connections been visually inspected for kinks and breaks? Were all items on the equipment manufacturer’s maintenance checklist completed? Were all LLDs confirmed operational within regulatory requirements? For any answer of “N” above, describe in section XIII how and when these issues were or will be corrected. XIII. COMMENTS XIV. VACUUM / PRESSURE/ HYDROSTATIC MONITORING EQUIPMENT TESTING Check this box if VPH monitoring is NOT used. (Do not complete this section.) This section must be completed if VPH monitoring is used to perform leak detection monitoring. System Type (Mark all that apply.) Vacuum Pressure Hydrostatic Sensor ID Component(s) Monitored by this Sensor Sensor Functionality Test Interstitial Communication Test Pass Fail Pass Fail Pass Fail Pass Fail Pass Fail Pass Fail Pass Fail Pass Fail Pass Fail Pass Fail Pass Fail Pass Fail Pass Fail Pass Fail Pass Fail Pass Fail Pass Fail Pass Fail Pass Fail Pass Fail Pass Fail Pass Fail Pass Fail Pass Fail How was interstitial communication verified? Simulated leak at far ends of the interstitial space. Visual Inspection Other (Describe the method in section XV below.) Gauge Was the vacuum or pressure restored to operating levels in all interstitial spaces? Yes No (Describe the reason in section XV below.) For any answer of “FAIL” above, describe in section XV how and when these issues were or will be corrected. XV. COMMENTS Advanced Compliance 3704 Littlefalls Ct. Bakersfield, Ca. 93308 661-706-4321 Fax# 661-589-9329 VAPORLESS MANUFACTURING, INC. LDT-890 Leak Detector Test Record Contractor: Advanced Compliance Customer: Gasko Date: 8/13/2019 Location: 430 E California Bakersfield, Ca. Product: 87 UL Technician: Bradley W. Hinsley Submersible Pump Identification Manufacturer: Redjacket Model No.: Serial No.: Notes: Leak Detector Identification Manufacturer: VMI Description: 99 LD-2000 Diaphragm-type: Piston-type: Tamper-proof seal installed: Other Style Leak Detector: Notes: Leak Detector in Submersible Pump Test at Dispenser Operating Pump Pressure (psi): 26 (para. 15) Gallons per hour rate: 3.0 (para. 22) Line pressure with pump shut off (psi): 18 (para. 23) Bleed-back Test with pump off (ml): 150 (para. 26) Step-through time to full flow (secs): 3 (para. 30) Leak detector stays in leak search position (Yes/No): Yes (para. 42) Leak Detector Test Pass / Fail Notes: Pass *Complete thermal expansion test before failing leak detector Advanced Compliance 3704 Littlefalls Ct. Bakersfield, Ca. 93308 661-706-4321 Fax# 661-589-9329 VAPORLESS MANUFACTURING, INC. LDT-890 Leak Detector Test Record Contractor: Advanced Compliance Customer: Gasko Date: 8/13/2019 Location: 430 E California Bakersfield, Ca. Product: 91 UL Technician: Bradley W. Hinsley Submersible Pump Identification Manufacturer: Redjacket Model No.: Serial No.: Notes: Leak Detector Identification Manufacturer: Veeder-Root Description: FX-1V Diaphragm-type: Piston-type: Tamper-proof seal installed: Other Style Leak Detector: Notes: Leak Detector in Submersible Pump Test at Dispenser Operating Pump Pressure (psi): 32 (para. 15) Gallons per hour rate: 3.0 (para. 22) Line pressure with pump shut off (psi): 20 (para. 23) Bleed-back Test with pump off (ml): 115 (para. 26) Step-through time to full flow (secs): 3 (para. 30) Leak detector stays in leak search position (Yes/No): Yes (para. 42) Leak Detector Test Pass / Fail Notes: Pass *Complete thermal expansion test before failing leak detector CERS = California Environmental Reporting System, ID = Identification, UST = Underground storage tank, ICC = International Code Council UNDERGROUND STORAGE TANK SPILL CONTAINER TESTING REPORT FORM (Page 1 of 1) Type of Action Installation Test Repair Test 12 Month Test I. FACILITY INFORMATION CERS ID 10132183 Date of Spill Container Test 8/13/2019 Business Name (Same as Facility Name or DBA-Doing Business As.) Gasko Food Mart Business Site Address 430 East California Ave City Bakersfield ZIP Code 93306 II. UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION Name of UST Service Technician Performing the Test (Print as shown on the ICC Certification.) Bradley Hinsley Phone # (661) 706 - 4321 Ext. Contractor/Tank Tester License # 971259 ICC Certification # 8373948 ICC Certification Expiration Date 8/10/2021 Spill Container Testing Training and Certifications (List applicable certifications.) 8/10/2021 III. SPILL CONTAINER TESTING INFORMATION Test Method Used: Manufacturer Guidelines: (Specify) Industry Code or Engineering Standard: (Specify) Industry Standard Engineered Method: (Specify) Attach the testing procedures and all documentation required to determine the results. # of Attached Pages Tank ID: (By tank number, stored product, etc.) 87 91 Spill Container Manufacturer: Phil-Tite Phil-Tite Method of Cathodic Protection Non-Metallic Non-Metallic Non-Metallic Non-Metallic Isolation Isolation Isolation Isolation Other (Specify in section V.) Other (Specify in section V.) Other (Specify in section V.) Other (Specify in section V.) Inside Diameter of Spill Container: (Inches) 15" 15" Depth of Spill Container: (Inches) 20" 20" Does the spill container have a 5 gallon capacity? Yes No Yes No Yes No Yes No Method to Keep Spill Container Empty Drain Valve Drain Valve Drain Valve Drain Valve Onsite Pump Onsite Pump Onsite Pump Onsite Pump Other (Specify in section V.) Other (Specify in section V.) Other (Specify in section V.) Other (Specify in section V.) IV. SUMMARY OF TESTING RESULTS Spill Container Test Results Pass Fail Pass Fail Pass Fail Pass Fail V. COMMENTS All items marked “Fail” above must be explained in this section. Any additional comments may also be provided here. VI. CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS TESTING I hereby certify that the spill containers were tested in accordance with California Code of Regulations, title 23, division 3, chapter 16, section 2637.1 and all the information contained herein is accurate. UST Service Technician Signature If the facility has more components than this form accommodates, additional copies of this page may be attached.