HomeMy WebLinkAboutBUSINESS PLAN MONIq[ RING SYSTEM CERTIF ATION
For Use By All .h,'ixdictions ~Vbhin the ~tate of Ccdfornia
.-l~'/~orio, Cire& Chttp~er & 7, Health and Scdk~ Code; Chapter 16, Division 3, Title 23, Cal~brnir~ Code ¢'Reg~da~ions
This fot-m tx~ctsr be used ro doc~ent test~g ~d servicing of ~onltoring equipment. A separate ce~ification or repo~x must be prepared
for each monirorine system con~ol panel by the rectmician who performs ~ work. A copy of this ~brm must be provide~ ;o the rank
sys[em owner/operator. The o~m'/operaror must submit a copy of ~is form to ~e local agency regnlating UST systems within 30
:4.. Central information
Factli'ty Name: /..~¢~¢ 7
S S
Facili[y Comacr Person:
Make, Model of Monkoring System: ~0~ ~OTO .~r! ~
g. tn'¢cmocy of Equipment Tested/Certified
.~lj_~c~ t~ff .:q~propriate goxes [o iadiea[e specific equipment inspected/service&
l_,Vf:mk Gauging Probe. Model: ..
Annuim' Space or Vault Sensor. Model:
Piping Sump i Trench Sensor(s). Model:
}:ill Sump Sensor(s). Model:
Mcchm~ical Line Leak Detector. Model:
~ k:l&.n'onic Line Let& De[ecmr. Model:
CI 'funk Overfill / High-Level Sensor. Model:
_-~_.Qj')_~'Lkspeci~: equipment type and model in
Tank kD:
53 iii- funk Gauging Probe. Model:
~3 .~mtHar Space or Vault Sensor. Model:
Ci Piping Sump / Trench Sensor(s). Model:
~ l:Jll Sump Sensor(s). Model:
Ci Mechmfical kine Leak Detector. Model:
CI tilecrronic Line Leak Detector. Model:
Section E on Page
~ llmlc Overfill / High-Level Sensor. Model:
~_ 9)[l?_¥~peci~' equipment type and model in Section E on Page
Dispenser ID: J "~
DLqpeascr Containment Sensor(s). lvlodel:
Shear \;alveks). -
~_ _t}i_.~p~2!ser Containmen[ Float'(s) and Chain(s).
Dispenser ID:
~g Dispenser Conminn~eht Sensor(s). Model:
~ Shear Valveks). '
~. [)~32~5~r Contaimnenr Float(s) and Chain(s).
Dispenser ID:
~ Dispenser Containmen[ Sensor(s). Model:
~ Shc:a' Valveks).
Bldg. No.:
Contact Phone No.: (~).
Dare ofTesth~g/Servicing: .._~/
Tank ID:
~ In-Tank Gauging Probe. Modek Jlr~_,.~ ......
~ ~nul~ Space or Vauk Season Model:
~ Piping Sump / Trench Sensor(s). Model:
~ Fill Sump Sensor(s). Model:
~ Mech~ical Line Leak Detector, Model:
~ Electronic Line Le~ Detector. Model:
~ Tm~k Overfill / High-Level Sensor. Model:
~ O~er (specie, equipment type ~d model in Section E on Pa~e.~; _ . _
Tank ~:
[] In-Tank Gauging Probe. Model:
~ Annular Space or Vault Sensor. Model:
rq Piping Sump / Trench Sensor(s). Model:
[] Fill Sump Sensor(s). Model:
[] Mechanical Line Leak Detector. Model:
0 Electronic Line Leak Detector. Model:
Tank Overfill / High-Level Sensor. Model:
. rq Other (specify equipment b, pe and model in
Dispenser ID: ,~'" ~/
Section E on Pa~e 2): ....
~[ Dispenser Containment Sensor(s), lvlodel: ~~__O.~_ ~
Ill Shear Valve(s).
~ Dispenser Containment Float(s) and Chain(s).
Dispenser ID: '~' ~'
III Dispenser Containment Sensor(s). Model: ~~_ ....
~ Shear Valve(s).
D Dispenser Contain,nent Float(s) and Chain(s).
Dispenser ID:
~ Dispenser Containment Sensor(s). Model:
[] Shear Valve(s).
~_l}i_Spenser Containmen[ Float(s) and Chain(s). rq Dispenser Containment Float(s) and Chain(s).
:qfrhc fiicilky contains more tm~ks or dispensers, copy this ~brm. Include information for eve~ t~k ~d dispenser at the facili~,.
C. Cerrilicafion - 1 certify that the equipment identified in this document was inspected/serviced in accordance with the manul~cturers'
guidelines. A[rached to this Certification is intBrmafion (e.g. manuthcturers' checklists) necessary to verify that this information
correc[ and a Plot Plan showing ~he layout of monitoring equipment. For any equipment capable of generating such reports, I have also
attached a copy of the report; (cheer all that t~pply): ~ System set-up ~rm hist~y~port
License No'-~ ~061/D40
'I'estingCompa~yNmne: RICH ENVIRONMENTAL PhoneNo.:(661 ) 392-8687
Sire Address: ~O ~L~3 X ~ ~g~l~&O~ ~ Date of Test~g/Servicing:
Page l of 3 03/01
5'loniroring System Certification
D. '~%sul~} of Testing/Servicing
Sofl-~; m'~ Vm'sion Installed:
~on, pietc ~he following checklist:
'¥ es ICi No'~ Is the audible alarm operational? _
Yes { CI No* isthe visUalalarm0perational? _
Y~-s ICl No* Were all sensors visually hxspected, functionall¥ tested, m~d confirmed operational9
j~ \'es / ~ No* Were all sensors Nstalled at lowest point of secondary containment m~d positioned so that other equipment will
not interfere with their proper operation?
Yes 1 ~ No* If aim'ms are relayed to a remote monitorhxg station, is all conmmnipations equipment (e.g. modem)
~ N/A operational?
'\' c-s~ No* For pYessurized piping systems, does thc turbine automatically shut down if the piping secondary comainment
l:J 'N/A monitoring system detects a leak, fails to operate, or is elecu'ically discom~ected? If yes: which sensors
positive shut-down? (Check all theft c~fl,oly) ~ Sump/Trench Sensors; 121 Dispenser Contaim~ent Sensors.
Did you confirm positive shut-down due to leaks at\~ sensor failure/discormection? IZl Yes; IZl No.'
¥c-s ~ No* For r'a_nk systems that utilize the monitoring system as the prhnary tarrk overfill warning device (i.e.
~[~ 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 p.e. rcent of tank capacity does the alm'm trigger? .
'~'cs:~~ No Was any monitoring equipmem replaced? If yes, identify specific sensors, probes, or other equipment replaced
m~d list the manufactm'er name and mod. el for .all replacement parts in Section E, below.
','es;" I ~ No Was liquid fotmd inside any secondary containment systems designed as dry systems? (Check all &al appl).?
I
Product; ~ Water. If yes, describe causes in Section E, below,
Yes I Gl No* Was monitoring system set-up reviewed to ensure proper settings? Attach set up reports, ifapplJcabie ____.~
[~1 YesI El No* Is all monitoring equipment.o.per'.at!onai p, er. manufact[~rer's specifications?
Section £ below, describe how and when these deficiencies were or will be corrected.
Commems: ~ ~/'/4-_ ~[ .~',att... $_..~ ~ I Od"/' ' ~0~
Page 2 ot'3
03/0
Gauging / SIR Ec
Cb. eck this box. gauging is used only for inven[o,-y
Check this box if no tank o o' o
~au=m~, or SIR equipment is installed.
This sec lion must be completed if in-tank gauging equipment is used to perform leak detection monitoring.
the following checklist:
Yes ICl No'* Has all input wiring be~n inspected for p. roper entry and termination, including testh~g ~or ground faults? '
Y cs / Ct No* Were all tanlc gauging probes visually inspected for danxage and residue buildup?
'~'cs/ CI No* Was accuracy of system product level readings tested? ......
'Yes [CI No* Was accuracy of system water levelreadings tested?
Xes [ ~ No* Were allprobes reinstalled property?
Y~s' I Iq No* Were all items on the equipment manu£~erurer's maintenance checklist completed'?
=' in 't'ne Section H, below, describe how and when these deficiencies were or will be corrected.
(~. Lille Lenk Detectors (LLD): gl Check this box ifLLDs are nor installed.
Complete tile following checklist:
Yes O No~ ~or equipment start-up or annual equipment 'certification, was a teak simulated to verify LLD perfo[mance'..'
~ N/A (Check all that ~p~o139 Simulated leak rate: {~3 g.p.h.; gl 0.1 g.p.h; gl 0.2 g.p.h.
Yes [] No* Were all LLDs confirmed operational m~d accurate within reg~tlatory requirements? -'
'x'es ~ No* Was the testing apparatus properly calil~rated?
'~'es I-1 N'o* 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 offifthe 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 offifany portion of the monitoring system malfunction~-
[] N/A or fails a test?
Yes [ [] No'* For electronic LLDs, have ail accessible wirbg connections been visually inspected? -
gq N/A
Y es I ~ No* Were all items on the equipment manufacturer's maintenance checklist completed?
the Section H, below, describe how and when these deficiencies were or will be corrected.
Page 3 of 3 o3/o ~.
¥1oni'toring System Certification
UST Monitoring Site [ lan
Date ,,,ap was drawn: __~/~/0~.
Instructions
If; ou ah-eady have a diagram that shows all reqmred information, you may include it, rather than this page, wkh your
Monitoring System Certification. On your site plan, show the general layout of tanks and piping. Clearly identil\'
locations of the following equipment, if installed: monitoring system control panels; sensors monitoring tank annular
spices, sumps, dispenser pasts, spill containers, or other secondary containment areas; mechanical or electronic line
del'colors; ~md in-tank liquid level probes (if used for leak detection). In the space provided, note the date this Site Plan
~x. as prepared.
Page bi of t,,..J os/m}
MONITOR CERT.
FAILURE
REPORT
ADD~ESS: 7~3
SITE CONTACT
THE FOLLOWING COMPONENTS WERE REPLACED/REPAIRED TO COMPLETE THE MONITOR
CERTIFICATION TESTING.
LIST OF PARTS ~EPLACED/REPAIRED:
REPAIRS:
LABOR:
PARTS INSTALLED:
'rHNK i F'RODUCt': UNLEHDED
i'.lO PF.'EUIOUS TI:INK ALARHS
TRtiK 2 ~ "'~' ' ..... .._
HO r:'F::EL i ]_S TIqNK P, LARI'iS
iiO PREVIOUS COi'ITRCT ALARMS
........ 'FRNK 'T-'I .........
::,~ IL r REPORT
HON MAY 24,04 2:52:0.3 PH
,-.Tm T T
LdCKY 7 HARKET
h iL~..:, ST.
~-SE~5".325-728J
r_,~p..l:~...:,r: ~ Lu., ~M,
FiS2E35E Fab f8 i997 N:32:20
TFINK i
T~NK iS: NORMAL
~','?~ OF TANK: ..,T,..EL
STEEL iNSIDE D!RMETER:
95.500 in
STEEL TOT~ UaUHE:iSeOB.E~ee gal
TILTED?: NO
8~WEEN FILL & CENTER.: NO
EETWEEN PROBE & CENTER:
0.000
BETWEEN PROBE & F~LL: 0.000 in
FUEL LEVEL 8 PROBE: 0,080 in
FUEL LEVEL E~ FILL: 0,000 in
PROEE S/N: 8ki5593i-G33-389~
~.u~,~ SPEED-O-WIRE:9.094 uSECyin
VERT!CgL SCALE~ 0~000 gal/in
VERTICAL HEIGHT: 0,000 i~
INIT'~IL PRODUCT LEVEL:
ir!~i:~L WATER LEUEL:0,250 in
HiM! ~LARI,I: 0,000 gat
HiGH ALARM: 0,000 gal
LOW FILARM: 0.000 gal
Hi WFffER ALARH: 0.~00
THEFT FiLARH: 20
LEAK gLARH: 0.2 ga!,"hr
PRODUCT: UNLEADED
TgNK IS: NORMAL
TYPE OF TANK: STEEL
ST~r,
,~ INSIDE DIAHETER:
9§ .500 in
STEEL TOTAL VOLUHE:t. 2080.800 gal
T!LT~D~. NO'
8ETWEEN FILL ~ CENTER: NO
BETWEEN PROBE & CENTER:
0,000
BETWEEN PROBE & FILL: 0,000
FUEL LEVEL @ PR]BE: 0,000
FUEL LEVEL @ FILL.: 0.000 in
PROBE S/N: 8W55931-G50-~097
PROBE SPEED-O-WIRE:9,~06
· UER. T!CAL SCAi K:
v~T~UAL n~l~ ~, 0.000 in
'INITIAL PRODUCT
. L~t,I~L.
16,850 in
i tiIIML. ,.,.IHTEK LEUEL: 0,250 in
alit .qLFIRM: 0,000 -'
n:,.~i-i ~LflRM: 0,000 gal
LOW FtLARH: 0,000 gal
Hf '~
WATER ALARM: 0,000 in
THEFT ALARM: 20,800 gal
~_~fi,, ALARM: 0,2 gal/hr
PRODUCT: PL US
UUItlHUI
SENSE:
TIED TO RELAY:
FOHTACT IS:
~NTRCT 6
NONE
HORMFIL
CONTI:ICT 7
~'.qr~_: CONT~:iCT 7
.::d't..-,c · N .0.
TiED TO RELAY: NONE
Q.'iNTACT I.S: NORMAL
CONTACT 8
!,iANE: CONTACT 8
SENSE:
TIED TO RELAY: HONE
CONTACT IS: NORMAL
CONTACT 9
i~AME: CONTACT 9
SENSE: N.O.
TIED TO RELAY: NONE
CONTACT IS: NORMAL
CONTACT 10
iqANE: CONTACT 10
SENSE: N.O,
TIE[:, TO RELAY: NONE
~ONTACT IS: NORMAL
.... CONTACT PROGRAM REPORT ....
,bH MAY 24,04 =,.~.~ PM
STATION NAME:
LUCKY ? HARKET
788 NILES ST.
1-805-S~5-?~8t
BAKERSF!ELD~ CA. 9~86
CONTACT 1
NAME: O]NTACT 1
SENSE:i N.O,
TiED TQ RELAY: NONE
CONTACT IS: NORMAL
CONTACT 2
N.qME: CONTACT 2
SENSE: N.O.
r,~zz, TO RELm'. NO,~.:
CU ~,.CT IS: NORMAL
CONTACT 3
NAME:
Dr'IX.Df ~
TiED TO RELAY:
CONTACT IS:
CONTACT 4
SENSE:
TIED TO RELAY:
CONTACT IS:
CONTACT 5
NAME:
SENSE:
~E~ Tn RELAY:
CONTACT I$~
CONTACT 1i
!'iAME: CONTACT 1i
SENSE: "fi
TiED TO R. ELAU: NONE
CONTACT IS: HORi'I~L
CONTACT 3
N.O.
NORMAL
I'
CONTACT 4}
NONE~
NORMAL
CO,"~, HCT 5 i
CONTACT 12
CONTACT t2
c. FI,.te r,
..... ,,~.. N.O.
TiED TO RELAY: NONE
NT,qUT IS: NORMAL
CONTACT i3
f'!AHE: CONTACT i3
SENSE: N.O.
TIED TO RELAY: NONE
CONTACT !S: NORMAL
CONTACT 14
~iRME: CONTACT 14
SENSE: N.O.
TiED TO RELAY: NONE
CONTACT IS: NORMAL
CONTFtCI' 15 ,.
!,lAME: CONTACT 1.5'
SENSE: N.O.
FIE[) l'O RELAY: ~NE
O_'iHTACT IS: NORMAL
CONTACT 16
~i~p£: COHT~CT 16
SENSE:
TiED TO RELAY: .. HONE
'N.O.' COHTDCT -o
i~: NORMAL
· NONE: ., .............. <. ......
NORMAL
CONTACT 1Z
HAME: CONTACT' i7
SENSE: i,i,rj:
TIED TFi RELAY: ~,,'~.c
CONTACT IS: h'OR~tPL
CONTACT 18
H~ME: CONT~CI' !8
SS~SE:
TIED TO RELAY: HONE
CONTACT !S: NORMAL
· CONTACT 19
HAME: CONTACT !?
SENSE:
TiED 1'0 RELAY:
CONTACT IS: HORM~L
CONTACT
~RNE: CONTACT
SENSE:
TZED TO RELAY:
COHTACT IS: HORMAL
CONTACT 21
~. ~Mc. ...
".'--'--. ' CONTACT si
c:.:NoE.
TiED TO RELAY: NONE
CONTACT
~.:,. NORMHL
CONTACT 22
ii,HE: CONTACT 22
E'F' "%"
,IH.=,_. H
~:z'- TO RELAY: NONE
F-F¢.'TPr~
,.......,ri, HoT tS: NORMAL
CONTACT 23
ii~i, iE: CONTACT 23
· x,'Ic, E. N
I'IED TO RELAY: NONE
CONTACT IS: NORMAL
CONTACT 24
N~NE: CONI'HCT 24
SENSE:
TiED TO RELAY: HONE
CONTACT IS: NORHHL
CONTACT 25
CO NT.qC T
St, ,r-C =
-'-['t---:,_.. :' ":
TIE[.', TO RELAY: NC, iiE
C:ONTDCT IS: HFIRHFi.
HAME: COHTACT 26
COHTACT 26
od'bE. ~, -
TIE[) TO RELAY: NC:NE
CONTACT IS: NORMHL
F:OHi'RCT 95
¢OHTAC'r £8
TiED TO RELAY:: HONE
C:OfTFRCT IS: HFjR. MAL
COHT~CT 29
!-!FINE: CO:fiTt:ICT 29
SENSE: H
.... :.lF!k
l'iFi) TO RELAY.'.
COH'TFCT iS: SILEHT'
I]Oii'FflCT 38
T~-~F', Tn ¢.,n ,-,v=_ NOHE
C ]Hi'ACT 31
i.!RHE: CO!iTACT 3i
SEiiSE~ H.O.
TiED ~u ~..:=M',', HONE
F':'-~HT r, ~- fO:
.... ~ H,..t ~o SILENT
,...L,f~ ~ ~ ~ ~ .-'£
~,~F: CONTACT 7o
· :,=.'-:,c, ii ,0.
TIE[:, TO RELAY: NONE
........ EEL.~Y PROGRAM REPORT .....
NON NAY 24,04 2:55:29 PH
STAT[Ok NAME:
LUCKY 7 HARKET
7~0 NILES ST,
!-885-525-728i
BAKERSFIELD, C~, 93306'
~,rED 'fO:
UM!H6:
RELAY i
RELAY !
not timed
N;qHE:
~"~O TO:
rZH!f, iS',
RELAY ~
RELAY '2
not tii~ied
T !EL-.', TO:
RELAY 3
RELFtY 3
not timed
HAME:
TiED TO:
~ ,,
Tiiii[.IG:
RELAY 4
RELAY 4
not timed
RELgY 5
H.;IME:
TIED TO:
RELAY 5
00018 sees
.... SENSOR PROGRAM REPORT .....
MON I'I~Y '24,~4 '2:.56:2~ I~1,~
STF,'T~ON NAME,'
LUCKY 7 ['IHP~K=T
7E~e NILES ST,
~-885~325-728~
BAKERSFIELD, E:A. 953~6
SENSOR 1
HRHE: SENSOR 1
SENSOR 1: no transducer module
OPEN BELOW: 8,00 mR
OPEN TiED TO: NONE
WATER BELOW: i4.88 ~
WATER TiED TO: N~iE
FUEL BELOW: 18,00 mA
FUEL TIED TO: NONE
SENSOR 2
NAME: SENSOR 2
SENSOR 2: no tr'msducer module
OPEN BELOW: 8.00 mR
OPEN TiED TO: NONE
HATER BELOW: 14,00 mA
WATER TIED TO: NONE
FUEL BELOW: 18,08 mA
FLEL 'FLED TO: NONE
TiED 'TO:
TiHiN6:
RELDY 6
RELAY
',
00010
~iRf'tE:
TIED TO:
TiMiN6:
RELAY 7
RELAY
00010
HAME:
RELAY 8
RELAY
00010
*COPY REQUESTED'PLEAS~
FAX(661)392-0621'
CXT¥ OF BAKERSFIELD
,OFFICE~ OF~.~VIRONMENTAL SERVICES
FAX' (~661) ; ~7_-ZI7~Z
" 'APPLICATION. TO PERFORM
FUEL MONITO~4G CERTIFICATION
FACH JTY
ADDRESS
OWNERS NAME.,
; ..... ~, ¢ ,
DOES FAQ~Y ~ DBP~S~.P~IS$ ~: ~S,,
NA/VIE OF TESTING COMPANY RI CH'' ENVIRONMENTAI~
' ':~:"'~'"' F'![
cONTR~CTORS.LICF.2qSE ~ 9 0 - 10 7 ~ :: ::'..
N~ & PHO~:~ER.OB CONTACT~SON JAMES RICH
DATE & T~ T~T ~ :TO BE CO~U~(~ ~/a Li / 0 ~/
TANK#.
,.¢
NO '~
APPROVED BY
::Z
66.1
s oF m?PUCANT
CONTENTS
/
MONIT ING SYSTEM CERTIFICATION
£or Use By All Jurisdictions Within the State of Cal~ornia
-.4zithorio; Cited: Chapter 5. 7, Health w~d Sc~eO, Code; Chapter ]6, Division 3, Title 23, Cal~brnia Code of Reguh~tions
This tbrm must be used to docmnent test~g m~d servicing of monitoring equipment. A separate certification or repot~ must be prepared
tbr each monkoring system consol panel by the teclmician who performs the work. A copy of this form must be provided to the tank
system owner/operator. The o~er/operator must submit a copy of this tbrm to the local agency regulating UST systems wkhh~ 30
days of test date. -
A. General Information
site <~ddi'ess: 'DOd ./,o t t..-~s5 :57"
Facility Contact Person:
Make/Model of Monitoring System: ~ ¢3../g
B. lnveutory of Equipment Tested/Certified
:~/l_lS_ck~d~e j?2~ropriate boxes Io indicate specific equipment inspected/serviced:
1~ la-'['ask Gauging Probe. Model:
[] AImuhtr Space or Vault Sensor. Model:
[] Piping Sump /Trench Sensor(s). Model:
Cl Fill Smnp Senso'r(s). Model:
CI Mcchmfical Line Leak Detector. Model:
~I Electronic .Line Leak Detector.
city:
Contact Phone No.: (__
Date of Testh~g/Servicing: (~ff/'/:2, _~_.~_.._
Model: .~]~ t~ ~ Electronic Line Leak Detector.
[] Tank Overfill /High-Level Sensor. Model: ~ Tank Overfill /High-Level Sensor. Model:
t-q _Otl~_cr~(speci~, equipment type and model in Section E on Page 2). ~ Other (speciff/equipment type and model in
~Fank ID: Tank ID:
~ ln-l'olfl4 Gauging Probe. Model: __ ~ in-Tank Gauging Probe.
Tank ID:
~ in-Tank Gauging Probe. Model:
ID Annular Space or Vault Sensor. Model:
t21 Piping Sump /Trench Sensor(s). Model:
ID Fill Sump Sensor(s). Model: --
[] Mechanical Line Leak Detector. Model:
Model:
Bldg. No.:
Zip:
)
[] Ammlar Space or Vault Sensor. Model:
[] Piping Sump / Trench Sensor(s). Model:
[] }?ill Sump Sensor(s). Model:
k_q N. lechmfical Line Leak Detector. Model:
Electronic Line Leak Detector. lVlodel:
"l':mlc Overfill / High-Level Sensor. Model:
Model:
~ Annular Space or Vault Sensor. Model:
['q Piping Sump / Trench Sensor(s). Model:
~ Fill Sump Sensor(s). Model:
121 Mechanical Line Leak Detector. Model:
[] Electronic Line Leak Detector. Model:
~_ Odier (speciS' equipment type and model in Section E on Page 2).
Dispenser ID:_____] ~ ~
~ Dispenser Containment Sensor(s). Model:
hiDShear Valve(s).
=CI~DJ_~_~?er Comainment Float(s) and Chain(s).
Dispenser ID: ~ ~' q
~ DJ.spenser Contaimnent Sensor(s). Model:
~1::> S hear Valve(s).
_O__[?.i_~nser Containment Float(s) and Chain(s).
Dispenser ID:__
[] Dispenser Containment Sgnsor(s).
'~ Shear Vah, e(s).
Model:
Section E on' Page 2).
CI Tank Overfill / High-Level Sensor. Model:
[] Other (speci .lq, equipment U'pc and model in Section E on Page 2).
Dispenser ID: ~ _~?
ID Dispenser Contair~ment Sensor(s). Model:
J~P Shear Valve(s).
CI Dispenser Containment Float(s) and Chain(s).
Dispenser ID:
[3 Dispenser Containment Sensor(s). Model:
12 Shear Valve(s).
[] Dispenser Containment Float(s) and Chain(s).
Model:
Dispenser ID:
[21 Dispenser Containment Sensor(s).
~1 Shear Valve(s).
· ~_j_D_i~s..~_nser Containment Floal(s) and Chain(s). [] Dispenser Containment Float(s) and Chain(s).
*If the bacility 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 manulhcturers'
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, [ have also
attached a copy of the report; (cheek all t/tat appl.)9:
Technician Name (print): ~~
C! System set-up [~afL,m history report
Signatu~~ - -
License. No.: 061/D40- ~8=09850
Phone No.:(66 1 .) 392-8687__
/Ot/~'5' ;~'---- ~gll~.t~,5~'z~'/~ _/') Date of Testing/Servicing:
Certification No.: 0 t~ / ~ jr
Testing Compm~y Name: RICH ENVIRONMENTAL
. dd,-ess:_ U c.V_v b. - Voo
/
Page 1 of 3 03101
Monitoring System Certification
D. Results of ~estmg/Serwcmg
$o£tx~.':are Version Installed:
Complete the following checklist:
[:}f15' Yes CI No* ls the audible alarm operati'ona[?
~ X:~:s ff.1 No* is the visual alarm operational?
ItW Yes ~ No* Were all sensors visually inspected, fimctionally tested, m~d confirmed operational?
~ Yes [] No* Were all sensors installed at lowest point of secondary containment and positioned so that other equipt~ent will
~ ~J(4- not imerfere with their proper operation?
~ h'es ~ No* If aim'ms are relayed to a remote monitoring station, is all communications equipment (e.'g. modem~
~ N/A operational?
[] Yes (ZI No* For pressurized piping systems, does the turbine automatically shut down if the piping secondary containment
'~3 N/A monitoring system detects a leak, fails to operate, or is electrically disconnected? lfyes: which sensors initiate
positive shut-down? (Check all that apply) ~ Sump/Trench Sensors; IZI Dispenser Contaimnent Sensors.
Did you confirm positive shnt-down due to leaks and sensor failure/disconnection? [] Yes; [] No.
ill 'X%s 71 No* For tank systems that utilize the monitorh~g system as the primary tmLk overfill warning device (i.e. no
~ N/A mechanical overfill prevention valve is installed), is the overfill warning alarm visible and audible at the rank
fill point(s) and operating properly? If so, at what percent of tar~k capacity does the alarm trigger?
Ci Yes* ~1' No Was any monitoring equipment replaced? If yes, identify specific sensors, probes, or other equipment replaced-
and list the manufacturer name and model ~br all replacement parts in Section E, below.
~ Yes* ~ No Was liquid fotmd inside any secondary containment systems designed'as dry systems? (Chect all &al
Product; tZl Water. if yes, describe causes in Section E, below.
~ Yes l-I No* Was monitoring system set-up reviewed to ensm'e proper settings? Attach set tip reports, if applicable /
~ Yes [] No* Is all monitoring equipment operational per manufacturer's specifications?
* h~ Section E below, describe how and when these deficiencies were or will be corrected.
E. Comments:
Page 2 of 3 03/0 !
F. l/n-Tank Gauging / SIR Equipnient:
Check this box if tank gauging is used only tbr inventory control.
Check this box if no tank gauging or SIR equipment is installed.
This section must be completed if in-tardc gauging equipment is used to perform leak detection monitoring.
Complete the following checklist:
~, Yes FI No* Has all input wiring been inspected fbr proper entry and termination, including testing for ground fimlts?
Yes _51 No* Were al'l tank gauging probes visually inspected for damage mad residue buildup?
'x'e.s ~ No* Was accuracy of system product level readings tested?
Yes [] No* Was accuracy of system water level readings tested? --
Yes ~ No* Were allprobes reinstalled properly?
Yes [] No* Were all items on the equipment manufactm'er's maintenance checklist completed?
the Section H, below, describe how and when these deficiencies were or will be corrected.
G. Line Leak Detectors (LLD): '~t Check this box if'LLDs are not installed.
Cf)replete the following checklist:
~ Yes [] No* For equipment start-up or annual equipment certification, was a leak simulated to veri~ LLD performance?
~ N/A /Check all that ap, v/y) Simulated leak rate: [] 3 g.p.h.; [] 0.1 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'?
51 Yes [] No* For lnechanical LLDs, does the LLD restrict product flow if it detects a leak?
~ N/A
~ Yes 51 No* For electronic LLDs, does the tm-bine automatically shut off if the LLD detects a leak? --
[2 N/A
-1~ Yes [] No~ For electronic LLDs, does the turbine automatically shut off if any portion of the monitoring system is disabled
[] N/A or discom~ected?
!~ Yes [] No* For electronic LLDs, does the turbine arttomatically shut offifany portion of the monitoring system malfunctions
[] N/A or fails atest?
~ Yes [] No* For electronic LLDs, have all accessible wh-ing connections been visually inspected?
[] N/A
~ Yes [] No* Were all items on the equipment manufacturer's maintenance checklist completed?
* In the Section H below, describe how and when these deficiencies were or will be corrected.
.il. Comments:
Page 3 of 3 o3/o ~
onilormg System Certification
UST Monitoring Site Plan
............. .........................
Date map was drawn: ~ / ~ / 0.~.
Instructions
if yoti ah'eady have a diagram that shows all required information, you ]nay include it, rather than this page, with your
Monitoring System Certification. On your site plan, show the general layout of tanks and piping. Clearly identil\,
locations of the £ollowing 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
detector>; and in-tank liquid level probes (if used for leak detection). In the space provided, note the date this Site Plan
was prepared.
Page gT/ of 9 0s/00
%ii( ~' PRO[:tiCT: UiiLFFIf)E[:,
i,.E7:
FUF:L. L~OE.~
kiiTf£R LEUEL.:
TEHP ::
:4-:3SS UTF.:.
L-ii<G;::!; IJLLFIGE ~
Tf$iK 2 PRODU'iT: FLUS:
L'U~?:,C.'I i '3 i I".' ] UO }
i' i
i:U£L LEUEL:
'FEHP ~
GROSS UTF~
i'fi!iK i PRODUCi'~ UNLEFIDED
"" ..... "'-', THHK REPORT
i -8¢S"325",7281'
ruu ::: !:LR7 i4:.]Z:28
'i
,.-' ,. NORH~L
';'<'! ;'=i
ij ._L :N~;YDF D!FtI'ETER:
~ .... · 95,508 in
~ f!LTED'?: -NO
'" ' · 16,850 ir:
0,~00 sM
8 ,:c~q gal
..i¢' F'i;'.EUrFiib~ '!'~:i'/K
· U:~.ik" '
:}; P~'F:5;i;. i': · PL J.¢.
F-L~RH REF'ORT
!JED$1PR 02.,8,$, 12,'.58:F.12 l:'I'1
~ft-l'[!ON Ht:iHE: ·
· .. :: LLiCKY 7 NI~RKET
, . ~ iiILES ST. i
· Bi~KER..q?IELD, CFI,
TFdK i PRODUCT: UNLEFtDED :
F.~H,, '~ PRODUCT: PLUS
. . NO PREVIOUS .TI:INK ALRRI'!S
, I:UCK. V 7 NF~RKET
7"~8 NILES ST,
E:FIKER % ':ELD,
Ui~L.Ei;:C,
i..i:iST 'O.j GPH TEST:
HOT i.ERRKED'
FF_2~
DEC:
NOU:
OCT:
LAST 0,1 6PH TEST:.
7.??'??';' 8~.¢j(jO:O6:80..aM
· .' '-' '
: · , . ,.:,. !. ,:[.::· ~"" ~...~;,-~-~-.i..~.?~:~L~-:.-..z.:-
· :~':tF:: · · "· ":'4;~i."
CUR~EHT STFITUS: "HOT
'~ ~' GPH FIOHT;~LY o.~,-.~., -
, ~:,.:,, NO.
F~..C~ GPH TEST ..... Y .....
FEB
' i)EC:
{40U:
OCT
~ :;':;'! '~ TEST:
,.. u,. GPH ·
........ L!HE LEHi< REPDRT
"?80 tiiLE~ ST. "
HONE
06/04/200@
].4,'29
PAGE 01/08
_R. I CH EI~_ IRO1VI~ENTAL
56~3 ~00K~ CT ~AK~.RSF~ELD,CA'93~08
OFFICE(661)392'8~87 & FAX (661) 392-0621
FAX_ TRA/~SMTTTAL COVER
Time:__ No.o~ page.:
From:_
06/04/2003 14:29 661392~! PAGE 02/08
MONITORING SYSTEM CERTIFICATION
For Us~ ~y Wll Jurisdictions F/ithln the State of California
;iuthorto, Cited: Chapter 6. 7, Health and Safety Code; Chapt~ 15, Division 3, Tide 23. Calibrate Code of Regulatlolg
Tibia form nxu~t be used to document testLug ~d aetvloiag; o~ moa {toting equipment. A seuarata certification orJ'enm't muat~o ~raam'od
~r. eac~ .monitor~a syste~ contro| 1~ne[ by the technician who performs the work. A copy of this form must bc p,'ovided to the tank
system owns/operator, The owner/operator must submit a copy of this fom~ to the Inca1 agency regulating UST systems within 30
days oftc~t date.
A. General Information
FacU.ky Contact Person:
Make,,/M.odel of Mcmltoring System: __~~l~'t~)
B. Inventory of Equipment Tested/Certified
Check I17 ~ppro )r d,te boxes to Indicate soeclfie cquioIneot iu.~pccled/se~,,,wieed:
~ tn-Tan~-'C]~u~i~g ~ robe~ Mbciel:
[] Ammlar Space or Vault Sensor. Model:
C3 Piping Sump /Trench ~en$o~,s). Model:
~ FlU Snmp Sensorial. Model:
CI Mechanical Line Leak Detector. Model:
~ EIcctronic .Linc ~ Detector. Model: '~"d~O __ __
C] 'ra~)k Overfill 1 High-Level Sensor, Model:
0 0d~cr (specie, cq_ulpm.en.t lype and mod, el in Scctj0n E 0n_~age 2)._
Tank
~' In-Tank Gauging Probe. Model:
0 Am~utm' Space or Vault Sensor, Model: __
~ Piping Sump / T~ench S&nsor(s). Model:
~ Fill Sump $OlSOr(S). Mod~:
~ M~hanie~ Linc L~ Da~cI~. Mo~[:
Elects,tic Line Lc~ ~t~tor, ~1: ~
T~tnk Overfill / HIgh-Levcl Season Mo~l:
~ O~c,' (sp~i~ equipmeni type ~d ~odsl in S~tio~.E o,~ Page
U Diipc:~ Contgnmcnl Sensor(s). ~odcl:
~Shca Valve(s).
._~ blsp~?~t ~a~nm~t Floaqs) ~d Ch~?iS).
Dispenser 10: ~ · ~
~ Disposer Containm~t S~so~s). Model:
~Shem' V~v~s).
_~_ pisp~ser CJmtalnmcnt Flea'is} ~d Chain(s}. ,
Dispenser ~: ~
Bldg. No.:
City: .~{~~ _ Zip: ~
Contact Phone No.: ( ._ ) .....
Date of Testing/Servicing: .~.~__/_.~.__O....T
Tank ID:
In.Tank Gauging Probe. Model; __
Anmflar Space or Vault Sensor. Model: __
Piping Sump 1 Trench 2{cnsor(s). Model: __
Fill Sump Sensor(s). Modet:
Mechanical Line Leak Detector. Model: __
Electronio Line Leak Detector. Model:
Tank Overfill / High-Level Sensor, Model: __
Other (spcei~ equipment type and model iq S,,ection E on Peg~_~),
"l'a n k Il):
C{ la-Tank Gauging Probe. Model:
0 Annular Space or Vault Sensor. Model:
[] Piping Sump/Tr~meh $~sor(a). Model:
C{ FiB ~ump Sensor(s). Model:
~ Mechanical Line Leak Detector. Modal:
C{ F. lectronic Line Leak Detector, Model':
~ Tank Overi~ll ! High-Level Sen~or. Model::
O Other (speciFy .equipment t~pc and model i,n
Dispenser ID:.
O Dispenser Containment Sensor[s), Model':
lip Shear Valve(s).
Iq Digpenser Containrn?nt
Dispenser ID:
O Dispenser Containment Sensor(s). Mode[:
O Shear Yelve(s}.
~ Dispenser Containment Ploa.t~ and ChainLs
Dispenser ID:
O Dimpen~r Containment Sensor{s). Model:
Section E On Page 2).
Dispeaser Conminment Sensor(s). Mc~ted:
Shear Valve(s), ' n Shear Velvets).
_{~{?pen,~cr Containment,Float(s)~_d Chaiu.(s). C3 Disposer Comainment Float(s} and Chain,s},. ,, . ,
*Ir'tile facility e$-~mins more tanks or dispensers, copy this fo~m. Include information for ~ve~y tank and dispenser at tlu~ feciliry.
C. Certification - [ certify that the equipment identified ia this document was inspected/serviced in nccor'danee with the manufocturerd
guidelines. Attached to this Certification Is Information (e.g. manufacturers' ehecldlsts) necessary to verify that this information is
correct add a Plot Plan shawin{ the layout of monitoring equipment. For any equipment eapnble of geuerntin{, such eeports, 1 have al.no
attached a copy of lhe report; (ca,eli all that eRgO'J; I-I System set-up ~ry report
'l'¢chnician Name (print): --s~-~L~{~ Signatu .r~ .---r~l~,.,~Jqr-.~-~r-~.
Certification No.: ..... ~ Liccnso. No.:
Testing Company Name: I~ICH ~NVIRONMENTAL
Page 1 0f 3
Monitoring System Certification
C6i/D40- ~8_09850
).
Date of Testing/Servlcing'.
03Y0J
00/04/2003 i4:29 661392~! PAGE 03/08
1), Results of Testing/Servicing
.~o~x~are Vcrsio~ installed:
Yes O ~o' [~ thc audible a~ opcmfio~tal? . , ......
Yes O No* Is the visual alarm operational?
Yes ~ No* Were all sens°m v~-~tly inspected, ~nc~onall~ m~*.ed~ ~d confirmed op~at~0nai?
Yes ~ No* '~ere alt'~flsors ~tatled ~t lowe~ point of~nda~ containment and positioned so that other equipment
Yes O No* if al~s are relayed to a remote monitoring station, is all comma~ications ~qutpment (~.g. modem)
Yes Q ~o* For pressured aiplng s~m,~s,'d~s the ~i~e a~tomatlcalty 'shill do~ ir cbc piping sccot~d~ conta[m~ent
~ N/A monitoz~ sysmm de.ets n le~ fails to ~erate, or is elecn'icatly dBcon~c~d? ffyes: which sentra
positive shut-do~? (Ch~c~ ~11 ~h~t e~p~) ~ Sump~mnch Sensors; ~ Dispe~er Contai~ent Scnsom,
Did ~ou ~onfi~ positive shut~own due t9 l~ and sensor ~/lurddisconnectlon? O Y.es; D No.
~'e~ ~ No* For t~ ~ysmms t~t udllz~"~ monitor~ system as the prima~ ta~ ove~ll wami, ns device (i.e. no
~ N/A men.ica] overfill prevcudoo valve is installed), is Oe overfill warning alarm v~ible and audible at thc tank.
fill points) an~ operating properly? .ffso, at what percent of tank ~pacl~ docs me alan~ ~i~er?
Y~s* ~ ~o Was any monitor~s equinem repla~ed? T. iycs. idcnti~ speci~ s~naom, ~obcs. or other equipment
a~d list ~e m~u~ur~ ~me and model,(or al replacement ~ts in Section ~, ~low.
Y~* ~ No Was liquid fo~d ~side any secondly ~tsinment sys~ms dmig~.ed as d~ systems? (L~,~ci ~11 ;h~
~oduct; ~ Water. lf~es, describe causes i, Section ~, below. .
M Ye~ Q No* Was monitoring sysmm set-~ reviewed to ensue pro, er se~nis~ ~ch set up ~cpom, it:applicable
~?"eS' ~ No* is ~l monitor~i equipm~t operat~pnal per m~u(~cturer's, spec~.Catlo~? , . .. -
* In Section E below, describe how and when lliese deficiencies were or will be corrected.
E. Comments:
:P~e 7. of 3 O.~lOt
06/04/2003 14:29
PAC~ 04/08
F. In-Tank Gauging / SIR Equipment:
[] Chcck &is box if tank gauging is used only for inventory
[] Cher. Jk this box [Eno tank gauging or SIK equipment is installed.
This sectiotx must be completed ii' in-tank gauging equipment is used to perform, leak detection monitoring.
Complete tan totlowm[~ enec~lm~[;, ...........
[~Yes [] Ilo= Has all input wiringbeen [n.spec'ted for proper entry and tem,dnation, [ncluding testing for ground fau}ts?
'~' es O No'*'" Were all tank gauging probes v~uaiiy insp"e'~tad for dat~age and residue buildup?
? ,Ye~' C1 No' Was licCumcy o'fsystem pr6dm:t level r~adi.gs teste~? ,,
/1~ .?es [] No;" Wer~'all pr°bcs rein.st•tied properlY?
~ Yes ~ No* Were ail it~.m~ on the"equipmeet'~ufaerurer's rr~inteuar~'c'~'eh~flclist ~ompl%d?
thc Section H, below, describe how and when these defieiencie~ were or will be corrected.
.Line Leak Detectors (LTL,D): ~ Check this box lf)..LDs are not jnstaJled.
[] Yes 13 No* For equipment start-up or mm•al equipmeut c, erfific~tion, was a leak simulated to verify LLD i~;'t".ormance?
~i~ N/A ~¢heckallthata~') Simutated leak rate: []3g.p.h.; rq0.] 8.p.h; CI0.2§.p.h.
-[:j- yes ~ Nu* Were ali L_LDs comZi.ru~ed oper~ion~.l, and a~curate'wjthin re~uJato.ry requkements? .....
[] Yes- [] Nr~ Was d~e testing apparatus properly caJibrated? .,,
CI Yes' CI No* For me~hani~i LLDs, doeJ'¥he LLD restrict pr•duet flow it;it detects a le~ic-? -'
~ N/A ..........
~ Yes [] No* For cJc'~-~mnJ¢ LLDs. d~es the turbine a~tomafica]ly sht~'~ ;)ff if the LLD'deteets a leak?
[] N/A
'T~ Yes [] 'No* For electronic LLD-~ does the turb{~e au~omati~aliy shut off if any portion of the m~)nitoring system is disabled
CI N/A or disc•tunneled?
1~ Yes CI No* ~or electroni~ LLDs, does the t~biae automatic~liy shut el'f if any portion of'the moaitori~"s'~-'stem m~tfunctions
~ N/A or flails a test?
~ Y~ [] No* For electro'hie LLDs, have 'all accesslbt~"wiring co[me~ions been vi$~ially inspected.~'
~ Y?.s -C3 No* were all items'"~?.~e equipment manufacturer'~'~aLnteuance ch,?st completed? ....
· ' In the Section H, below, describe how and when these deficiencies were or will be corrected.
Comments:
Page 3 of 3
6/84/2883 14:29
66139~1
PAGE 85/88
Monitoring System Certification
UST Monitoring Site Plan
si,~ ^~d,,,~.,: d.U.t.~7, ~.,, ~oo_..~uxl~~,-- 1:~.~'2..--c~-~_ ~_._,o., ~ ·
.................. ................. ..................":i: ~:: i i i i i~ .~.~i i i i i i ! i ! i i, ~:
:::::::::-.:-P~.~.'~,~,r .... :..::~. ::::::::::::::::: ~'
:::::::::::::::::::::::::::: ::::.:::/ .............. ::: ~:
:':'::::::: :~? :~ ~..r~::::::..::: ..... :::::::::::
...................... :...:../-.~....,__,_. ................
..................... : ~,~t. ~ .......................
Date map wes drawn: /f'
Instructious
]f you already have a diagram that shows nj1 required information, you may include it, rather than this page, with your
Monitoring System Certificafio.n.. On your site plan, show the general layout of tanks and piping. Clearly identify
Ioc0tJons of the following equipment, i,f inst~llcd: monitor~g system control panels; sensors monitoriog tal~k annular
spaces, sumps, disjpc~ser pans, spill con~alners, or other secondary containmo~t areas; mechan, ic~l or electronic tine leak
detectors; and iii-tank liquid level probes (if used ~'or leak detection). In the space provided, note the date this Site ?lan
was prepared.
Page .~ ._ of..~
I~ $~-~lOU$ mN(
I'RHK, 2 pl~ff.~c'r:. H. US,,
-qHK "L P~DU31':' tJNLEI~B
PAGE
OCT t
07/08
29 661392~!
IO:14 BK~FI_D FIRE PR~¥;~NTION
[ 861 ) tl52-217P.
PAGE 88/88
MRR 28 2003 10:14
SFLD FIRE PREVEMTIOM
1) 852-2172
p.1
02/2?/2003 16:91 6613920621
PAGE 81 / 81
*COPY R~QUEsT~D PLEASE
CITY OF BAKERSFIELD
OffiCE OF F. AWVIRON1VIENTAL SERVICES
1715 Ches~er Ave., Bakersfield, CA (661) 526-3979
fax {~6) 326-0576
APPLICATION TO FERFOR,M
FUEL MONITORING CI~RTII~ICATION
~D~S ~' ' ~ ·
O~ ~ ~