HomeMy WebLinkAboutfmc result 2004
Q~Y;
'Z
\'
MONITORING SYSTEM CERTIFICATION
For Use By All Jurisdictions WiThin the Stale of C(¡Jifornia
.-uI¡¡'¡oriry CiTed: Chuprer 6.7, HeaÙh and Safety Code,' Chapter 16, Division 3, Title 23, California Code ofRegulmions
~
'Tbis fonn lllLlsr be used {Q document testing and servicing of monitoring eql~ipment. A separate certification or report must be prepar~d
['or di:h moniTOring s)'sœn1 control panel by the œchnician who performs the worle A copy of this form must be provided to the mnk
sy~[cm oWller/operaror. The owner/operator must submit a copy of this form to the local agency regulating UST systems wirhin 30
Lbys (If [¢St dmè'.
A_ Gt:.íierallnformation
hi:ility Name: (! oH )J!J Y'S /ly¿~
Sile A.ddrèss: -~L2.- t3u.. t.M- ~UJ 'EAJ~ (3t,.,tJD
faciEr) COnnIC! Person:
OCT 2 fBlªgO~o.:
City: -f3A¡'(~~1?u? Zip: _______..
Comact Phone No.: ( )
I
I:
rdàtc:lvlodèl of Moniroring System: -:{AJ ((lu ~S-J 001} Date ofTesting/Servicing: -'D-/~/J¿Y
R l.nveJ.ltory of Equipment Tested/Certified
Cli_""I~ dJ~ _''22.fO rÌare bùxes w iudicarc s ccilie e Ili men[ ius ¡ccrcd/seJ'vÎCcd:
!li-'LyJiclD:__J.!}Ll- ~,., .:,. M~~¡¿ TanklD: ~AII-ql
Iii Cl( In-Lmlc Gauging Probe. Model: MA~ ( œ'Ín- Tank Gauging Probe. Model: .M4-1
'I 0 Annular Space or Valll! Sensor. Model: 0 Annular Space or Vault Sensor. Model:
I alPipmg Sump i Tn;nch Sensor(s). Model: *'!.¡.J(,w '~LoJí( ¡¡('Piping Sump / Trench Sensor(s). Model: ~,~.,J --¡::¡;;;;:'¡:-=~--
o Jill Sump SënsOr(s). Model: 0 Fill Sump Sensor(s). Model:
¡j(¡"kchanic,1l Line Leak Deæctor. Model: ";';.0 ~/Í cJ"Mechanical Line Leak Detecror. Model: ~ ~
o LkL'¡l'Onic Line Leak Detector. Model: 0 Electronic Line Leak Detector. Model:
o Lmk OVè'rtìlll High-Level Sensor. Model: 0 Tank Overfill / High-Level Sensor. Model:
, O__ºp-)~'JJ:; ,èCÜ\-' è' uj menr r' e and modd in Section Ë on Pae 2 . 0 Other (s eci 'e wi ment t e and model in Seerion E on p~ ~ 2).
Tyk W: 11 ,.}, - V'ì, 5 L,A~ Tank ID:
l1!!' 11l- Lmk Gauging Prok Model: MA..Q,. -( 0 In-Tank Gauging Probe. Model:
I [] ,-\lUlUI;}r Space or Valllr Sensor. Model: 0 Annular Space or Vault Sensor. Model:
it œ'Piping Sump I TreJlch Sensor(s). Model:'1~ (,lJc) -Ç~ 0 Piping Sump / TrenchSensor(s). Model:
I, 0 FjJJ Sump SeJJsorls). Model: 0 Fill Sump Sensor(s). JVlodel:
I ~ki:h'U1i(;al ~ine Leak Detector. Model: 0 Mechanical Line Leak Detecror. lvlodel:
[J l:lei:!mlllC LIne Leak DeIector. Model: 0 Electronic Line Leak DeteCIOr. Model:
I [] LU1k OVCfiìJJ / High-Level Sensor. Model: 0 Tank Overtìll / High-Level Sensor. !vfodel:
II q_tJ[llèr_,SEècif~i è( ui mem tV e and model in Section E on Pae 2 . 0 Other (s ecify e tli ment tv e and modd in Section E on Pa e 2L _
I DisfJcnscr lD: I .. '2... Dispenser ID: ~- 'if
ifDisPèlbèf Con¡ajnmenr Sensor(s), Mockl: -ÄJu ,AJ'f. ~Dispenser Containment Sensor(s). Model: ÄJfJ w"
¡ Œ"'SJ¡car Valvèls). ~ Shear Valve(s).
I _º L~i~~E.~_Il~tr Conrainmenr Float(s) and Chain(s). 0 Dis enser Containment Float(s) and Chain(.s).
[ Dispdlscr lD: 1- " Dispenser ID:
! tYDispel1ser Conrainmem Sensor(s). Model: AJd.oJ2. 0 Dispenser Containment Sensor(s). Model:
!¡lY'Sllè;¡r V,lIve(s). 0 ShearValve(s).
II 0,_: Di~p_è~l?,~r Containment Floã[(s) and Chain(s). 0 Dis enser Containmem Float(s and Chain(s).
I J?~pènser lD: 5" ..~ Dispenser ID:
I!¡' (!f Dispèlbèr Conrainmem Sensor(s). Model: AJ fJlJ1! 0 Dispenser Containment Sensor(s). Model:
III ~t1c~:U: VaJwls). 0 Shear Valve(s).
~gDj_~~ns.:r ÇÜJJl;;Ünmenr Flout s) and Chaín(s). 0 Dis enser Containment Float s) and Cha.in(s).
'lÙ]¡", ÙlciJÚy contains more tanks or dispensers, copy this form. Inc1ude information for every tank and dispenser at the tàciliry.
C. Certification -1 certify that the equipment identitied in this document was inspected/serviced in accordance with the manufacturers'
guiddines. Attached to this Certification is jnformation(e.g. manufacturers' ctlecklists) necessary to verify ttlat ttlis information is
~OlTCC( and a Plot Plan showing the layout of monitoring equipment. For any equipment capable of generating such reports, 1 have ¡~Iso
,mached a copy of the report; (check aJ/ 1hilt apply): Q System set-up 0 AI· 1 history re rt
r~dHÜciàn Name (prim): ~M ~f) '(f' ~ cu- Signature:
I
J
II
CeniIkarion Nù.: O-a.( I 2~'f1#3
C61/D40- #809850
¡.
Phone No.:(661 ) 392-8687
Date of TestinglServicing: JfLI1..-j Q-lf.-
License. N
lesring Cùmpany ~ame: RICH ENVIRONMENTAL
Silc' Ai.il1rèSS: Ailed -2~(2.. ßu ~""'AJS ßWp·- ßA1¿~f'J.~ oL
Page 1 of3
03/0 i
J\'lúJÚwring System Certification
Ü. i{¡cSliÍlS 91' TesIÌug/Servicing
Sùlr\\ ,ifè V è1'sio11 installed:
., C~'i)klC rhe fùUowiu'" checklist:
\I ~lt, Ö,' I 0 No:: Is me a~dible alarm 0 er~tioIlal?
Ii: y, \~ U No'" Is d1e vIsual alarm 0 eranonal?
l ~ \;C~ I 0 No; ; Were all sensors ~isualJ ins ected, fu~ctionall tested, a.nd c.onfinned ° era.ti.onal?__~
II ¡ mONo'· Were all sensors ll1stalled at lowest pomt of seconda.ry comal11ment and posLtLoned so that other equipmenr will
I nor interfere with their ro )er 0 eration?
'1-----
II U ): éS O/No* If ala.rms are relayed to a remote monitoring station, is all communications equipment (e.g. modem)
\ / lit N/A operational?
I LV\ èS 0 No'" For pressurized piping systems, does the tmbine automatically shut down if the piping secondary COnrail1Jll~Il[-
III 0 N!A moniroring system detects a leak, tàits to oper<)Ke, or is electrically discorulêcted? If yes: which sensors iniria\~
! posÜive shut-down? (Check ,Ill rhm apply) I1!f SLimp/Trench Sensors; 0 Dispenser ~~tainmem Sensors.
I, Did 'ou confirm ositive shm-down due to leaks and sensor failure/discormection? Œr'\' es; 0 No.
i[ 0 't(,,; 0 No" For ra.nk syslèms that utilize the monitoring system as the primary tank overfill warning device (i.e. Ill)
I ~N/A 1~1ecba~1ical overtill pr~vention valve,~ installed), is the overfill warni~g alarm visible and. 3L1di,bJe at d1è mJ1l~
I till olTIr(s) and 0 eratm" )1"0 erly? It so, at what ercenr of tank ca aCI does tlpe alarm tnú"er? "~."
I U -Y--.::> " Was any monitoring equipment replaced? If yes, identify specific sensors, probeß, or other equipment replaced
i and Jist the manLltàcturer name and model for all re Iacement arts in Section E, ~elow.
I 0 \.;.:)'" Was liquid fOlmd inside any seco.ndary cont~inllle~t sysrems designed as dry syst¢ms? (Check all Thai appÖ) 0
I Product; 0 Water, If es, describe causes m Secnon E, below. I
¡j"Jì' è:> 0 No* Was monÜorino- s srem set-u reviewed to ensure TO er settino-s? Attach set u licable
sf y ö 0 No* Is all monitorino- e ui menr 0 erational er manufacturer's specifications?
õ' iü S,"ccioll E below, describe how and when these deficiencies were or will be corrected.
t. CüHlllleìHs:
._--_._,-~..
.__._~ .----.
-.'---_.-
----.-,--.--.
.__..._ _ o_u ._.
....._.,._'__u
."__ __ ___u_ _._
..----..--.----....---
-----.---.-..-.
... -- -------.
.-----------.. --.
.. -..-----...
.------. ,.------
.----.---.-.--..
___n'__'..
- . ---~-_._..._----
..____n____
___._.___.~__n_
.-----.-.- -
_._..__._..__u
Page 2 of 3
OJJO I
li. l~_rl"ml: Gauging / SIR Equipment:
cI Ch¢ck this box. if tank gauging is lIsed only for inventory control.
o Check this box if no tank gauging or SIR equipment is inswlkd.
This sèèLÌon must be cOl1.1.pleted if il1.~tank gauging equipment is used to perform leak detection monitoring.
Co Bi'..!':lt: tile îùUowino checklist'
1 .~
0 \··....:..s 0 No; < Has all input wiring been inspected forprop.er entry and termi.nation, including testing for ground faLÜts?
------ Were all tank gauging probes visually inspected for dan1age and residue buildup?
0 Ye,S U Nù*
0 Was accuracy of system product level readings tested? .-.
0 Yc's No*
o '~~.:S I U No* Was accuracy of sysœm water level readings tested?
I
o YèS \ 0 Nù'" Were all probes reinstalled properly? :1
[T--
o \' èS 0 No* Were aU items on the equipmem manufacturer's maintenance checklist completed?
". III rlH: Sc:criòn B, below, describe how and when tbese deticiencies were or will be corrected.
G. .L. i.n t Le.tk Detectors (LLD): ¡'Cheek this box if LLDs are not installed.
CÙllì ) erl' {It' 0 O\\IfJ~ C ec \.1S :
't' eS 0 No* For equipment start-up or al1llUaJ equipme~ertification, was a leak simulated to verify LLD performance'!
0 N/A (Check all ¡hm appl>~ Simulated leak rate: 3 g.p.h.; 0 0.1 g.p.h; 0 0.2 g.p.h.
rt-v èS 0 No* Were all LLDs confirmed operational and accurare within regulatory requirements?
r{ ). èS _.
0 No* Was me testing apparatus properly calibrated?
~~
Yö o No* For mechanical LLDs, does the LLD restrict product flow jf it detects a leak? I
o N/A
0 Yes o No* For eJ"'tronic liDs, does 'he 'w-bine automaricalJy shut off if the LLD detects a leak? 1
[?' N/ A
f----- For electronic LLDs, does the turbine automatically shut off if any portion of the monitoring system is disabJ.:d
DYes o No; ;
ØN/A or disconnected?
1---' \'\:'5 o No* For electronic LLDs, does the turbine amomatically shut otT if any p0l1ion of the monitoring system maltlmctions
u
(J N/ A or fails a teSt?
o ìtS o No* For electronic LLDs, have all accessible wiring connections been visLlaJly inspected?
cÝ N/A
M 'l'tS ..
o No* Were all items on the equipment manufacturer's maintenance checklist completed?
---
j f 11 r a hI-I' t
'" in {he Secrion H, below, describe how and when tbese deficiencies were or will be corrected.
H. CÛ1H.menrs:
._---._-
..-.....-.....---
Ì) Í).t\JL- ~") -M^,fi~'" R.~o ~c'K~ -~L.. - 5'f(L -:# {AD RfAOAgJÆ:
. ---'..---
~ ~M~ Cilt
~~ ~~ 1'1-1
S €~ #' '3, "<00-1 i''22-
.- .-- -. .------ .
.... ---...----
Page 3 01'3
03/0 I
~
l\'loniwring Sysrem Certification
Sile Addre;;;;: ~ {.\AJ AJ yC;
[:
\
" . CO·µ·
. ~~. . .
D .~ j\J
,UST Nlonitoring Site Plan
A (¿"l~) .2 <8 11- (3u <.M.- O()J~ -O~ R L,rfj - ßA (,,(:ðtm17HLJ~ ~
· . . .
"-=-~
---'....r-- .
. - - . . . 51 . . 5'6 ~ð,(j
. Çl(.>trJ~. '!t~r . ~. _
~ðj'(A
. '1l:
tlµLi'I' . CC,o~.grI
. .. . /äc¡¡f,IL
~.
· . . .
$"':
· . . .
. ...
.~'
r· . í
~
:~ ti. ~(
.1J1Jtf0/l.
~.
g
o
C.
:A:N!'J:(.4.~ ?/~:
. . . S1!l;15.oA$. . . .
Date map was drawn: -12J -Ý-./ V ~
Page _GÍ_
If YCIU already have a diagram that shows all required information, you may include it, rather than this page, with your
MùnÍloring System Certification. On )/our site plan, show the general layout of tanks and piping, Clearly idènl ií\
loc,ìliùlb 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 kak
d~le<':(Qr$; and in-tank liquid level probe~ (if used tòr leak detection). In the space provided, note the date this Site Plan
\\¡l" prepared.
Instructions
05/00
MONITORING SYSTEM CERTIFICATION
For Use By All Jurisdictions WiThin the Stale of California
,·ju¡horil)' Cired: Ch¡¡pær 6.7, Healch and Scd'ety Code; Chapter 16, Division 3, Title 23, California Code ofRegu/CJCíol1S
Tllis fürm muse be used w document. testing and servicing of monitoring eqLlÌpment. A separate certification or report must be prepa '~d
['or è~t<:h monÌToring SVSIeI11 control panel by (he œclU1ician who pe:rforms the work. A copy of this form must be provided to the tank
S)'SlèJll o\\'ller/operawr. The owner/operator must submiT a copy of this form to the local agency regulating UST systems wirhin 30
Lby:; ()f l('Sr darè.
A. G êiìërallnformation
FaCllity Nml1e: .:::r 0 ~ )J}oJ 0/'> A,¡¿c.o
,
Si{(.' .-\ddrtss: -2..-.k-.L2.-- (3uc41 aUJf-v~' ßLup
Facilil) CùlllaCI Person: ___
lvbLè: 1\10 del of Moniroring System: "'0 N ~ A} )( ~ c., "
Bldg. No.:
City: ßÂ~-¡;:¡£u) Zip: __.____-.
Contact Phone No.: ( )
Date of Testing/Servicing: .J..Qj ()" ! ~'1--
B. 1.J.1Vcilwry of Equipment Tested/Certified
Çliè'I;lhc1.Q£ro riilre boxes [0 iodic,¡¡c s ccitic c ui mCllr ins Jeered/serviced:
1':ì'iUD: ._--'..L.hJJ....-~ ......~oÂ.C)~
o !ü-Lmk Gauging Probe. Model:
c¡(,-\llIlUlar Space or Vault Sensor. Model:
o Piping Sump i Trench Sensor(s). Model:
o FiU Sump Sè:flSor(s). ModeJ:
o t\kduu1ical Line Leak Deœcror. Moclè1:
o Lkctronic Line' Leak Derèclor. Model:
o LllIk OVèrÎí1J I High-Level Sensor. Model: _
o ûrl!~'r_~s .ecit\' è ui 1fi1è.nt I' e and model in Secrion E on Pae 2 .
Taul\. 10: LA. AJ ~ C( '1 - :S J.. ¡,4t) ¡¡
o )ll- !'ank. Gauging Probe. Model:
¡¡( .-\.1iHutar Spacè or Vaul! Sensor. Model:
o Piping Sump I Trench Sensor(s). Model:
o FjlJ Sump Sensorls). Model:
o i\kch:lJlicat Line Leak Detector. Model:
U Lkclrollic Line Leak Detector. Model:
o LU1k. OvtrJ:Ì1J! High-Level Sensor. ModeJ:
o Urhèr l~Eè(;ifYè( ui mènl ry e and model in Secrion E on Pae 2 .
Dispenser W:
o DispêllSèf COlHainmenr Sensor(s). M9ctè1:
o Shear Valvèls). :
I
_9 L~~)£~llse:r COl1lalnmeI1l FJo¡1r(s) and Chain(s).
. OisptHser W: !
o DisµèllSCf ConrainJl1em SeJ1s0r(s). Mbdel;
I
o Sllè;.¡r V,l1vè(S). ,
Q Di~.p_è[bè:r COl1lainmem Floar(s and Cbain s).
Dispenser ID:
o Di~[J':ll:ièr Coorainmem Sensor(s). Model:
o Stl¡;~U' Valvèls).
I. Opj.~ èl1Sèr ÇomillnmèlH FlOUt s and Chain(s).
'lÎ rlle' f;.¡.:;ijiLy conrains more tanks or disp~nsers, copy this form.
Tank ID: (JA;fM "',
o In-Tank Gauging Probe. Model:
CY'Annular Space or Vall It Sensor. Model: _______
o Piping Sump / Trench Sensor(s). Model:
o Fill Sump Sensor(s). Model:
o Mechanical Line Leak DetecIOr. Model:
o Elecrronic Line Leak Detecror. Model:
o Tank Overfill / High-Level Sensor. Model: '____"__
o Other s eci e ui ment t e and model in Section E on Pa è :n.
~I
........ !
---_.._-"_.-
TankID:
o In-Tank Gauging Probe. Model:
o Annular Space or Vault Sensor. Model:
o Piping Sump / Trench Sensor(s). Model:
o Fill Sump Sensor(s). Model:
o Mechanical Line Leak Defector. Ivlodel:
o Elecrronic Line Leak DefecTOr. Model:
o Tank OveríìIJ / High-Level Sensor. Model:
o Other (s eei e ui ment tv e and model in Section E on Pa è 2).._ .
Dispenser ID:
o Dispenser Containment Sensor(s). Model:
o Shear Valve(s).
o Dis enser Containment Float(s) and Chain{s).
Dispenser ID:
o Dispenser Containment Sensor(s). Model:
o Shear VaJve(s).
o Dis enser Containment Floa¡(s and Chain(s .
Dispenser ID:
o Dispenser Conrainmenr Sensor(s). Model:
o Shear Valve(s).
o Dis ense!' Containment Float s and Chain(s .
Include information for every tank and dispenser at the facility.
.--.-.....-.
C. Certification -1 certify that the equipment identitied in this document was inspected/serviced in accordance with the manufactl1l'1~rs'
guiddini:s. Ar[¡¡ched to this Certification is information (e.g. manufacturers' checklists) necessary to verify that this information is
~ùrrec( alld a Plot Plan showing the layout of monitoring equipl~ent. For any equipment capable of generating such reports, 1 have ¡\lso
;\r(¡¡ched a copy of the report; (check 11/1 fhilt apply): Q System set-up 0 rm hist y re(! rt
fèdlllician Name (prim): ~k:8 <::f Rl C/II Signature:
C61/D40- #809850
...
TesÜngCùl1lpany~ame: RICH ENVIRONMENTAL PhoneNo.:(661 ) 392-8687
S [re' AdLiress: AltCo - '2 (L ( 2... ßtA.cAL ö ().) '/f.bS ß Wp~ ßA~ Date of Testing/Servicing: .AU .£._j _ ø ~
"0(, '1(')(,01
--_._-_-0_.
CeniÜcaIiùl1 No.:
License.
Page 1 of3
03/0J.
1\¡.1¡jjwrj }~ System Certi1ïcation
V. KdUhs 01.' Testing/Servicing
Sùl[\\ ; rè V èrsiün lnsmlled:
~1jj!èr" cht íollowil1" checklist:
lru .Y èS I 0 No'" Is [he a~dible alarm 0 er~tio!lal?
I ~ ~ 0 No'" Is d1e visual alarm 0 eraHonal?
I ~\;~-s \ 0 No* Were all sensors ~isualJ ins ected, fur;-ctiol1all tested, and c.ontìrmed 0 er~ti.ona)? . __:_
\, ~\~ 0 Nù' < Were all sensors ll1stalled at lowest pOlllt of secondary contamment and poslIloned so that oTher equLpment wlll
I nor imerfere with meir 1'0 )er 0 eration?
\i O\~s 0 )'Jo* If alarms are relayed [0 a remote monitori.ng station, is all communications equipment (e.g. modern)
\ (]" N/A operational?
\ 0 -\ ç~ O..,No* For ~re~surized piping systems, d~e.s the tLlrbine allt~matical~y shut .down if the pip,ing secondary conrainmènr-
l]( N/A mOllHonng system deœcts a leak, tails to operate, or lS electrically dlscoCUlected? If yes: which sensors iniriaLL'
I posiTive shUT-down? (Check 'Ill fhm "pply) Q Sump/Trench Sensors; Q Dispenser Containmem Sensors.
I Did 'Oll confirm ositive shut-down due to leaks and sensor failure/disconnection? 0 Yes; 0 No.
1'1-0 't é'S 0 No* For rank systems that utilize the monitoring system as the primary tank overfill warning, device (i.e. lW
I' tif NiA mechanical overtìll pr~ventioL1 valve i,s installed), is the overfill warni~g alarm visible and. aLld~ble at the rank
\ tìH oin[(s) w1d 0 eratln0' )ro erly? It so, at whaI ercent aftame ca aCl does the alanD [n\f~)èr? i~,'O
liU--\ 2';'" Was any monitor~1g equipment replaced? !fyes, identifY specific ~ensors~ probes, or other equipment replae¡;d
I and list me manutactw'er name, and model for all re lacement arts 111 SectIon E, below.
I 0 \.;;,;'" Was liquid found inside any secondary containment systems designed as dry systems? (Check all [hm apply) 0
_L Product; 0 WaTer. If es, describe causes in Section E, below.
~~;":S 0 No* Was monitorina s stem ser-u reviewed to ensure fO er settinas? Attach set u licable
¡¡(Yö 0 No* Is all monitorina e ui ment 0 erational ermanufacturer's s ecificarions?
,~ In Si.'crjoIl E below, describe how and when these deficiencie~ were or will be corrected.
__JI
£. CommenTS:
._._.__.....~--_.
---'.. .----."-
_.-.. ---------
---.-----..
_____ .-_.0- _._.
---_._- -.-.
----.---..'-.
---.-----.--..-..-.". -.
---.----.-
-----_. ._-----
------ .----.-.--""
---------
-<.-.----
----.----- --"
-..-----".
Page 2 of 3
0310 I
I". l.J-ri\'ilk' G.:mging I SIR Equipment:
O~heck th~s box. ~ftank gauging. is used only for invemory COfl[¡,·~)1.
œ" Check thIS box If no rante gaugmg or SIR equipment is inswlkd.
This sècÜon 1l1.l.ìst be con1.pleted if in-tank gauging equipment is used to perform leak detection monitoring.
C0 l\.l!.!dè ¡lit îùllowino checklist·
1 , .~
h~-~~ d 0 No'" Has all input wiring been inspected for prop~rentry and termination, including testing for ground faults? I
o Yl'S U Nù* Were all Larue gauging probes visually inspected for damage and residue buildup?
0 Was accuracy of sysœm product level readings rested? --.--
0 y c'S No*
O~\~ èS I 0 No'" Was accW'acy of system water level reading$ tested?
o Yè'S I U No" Were all probes reinstalled properly? __I
ß---- 0 No* Wert: aU iœms on the eqllipmem manufacturer's maintenance checklist completed?
o \'cs
;, 111 fllt: Section H, below, describe how and when these defich~ncies were or will be corrected.
_/ p~ 0 A) CJTrr6fl M 114fiTM.. ~
G. Lint" Le.d( Detectors (LLD); C! Check this box ifLLDs are not installed.
CÛllilJIeIl' The fo lowinl! c ec.: 1st:
U YèS 0 No* For equipment start-up or annual equipment certification, was a leak simulated to verify LLD performance'ì
0 NlA (Check all thal apply) Simulated leak rate: 0 3 g.p.h.; 00.1 g.p.h; 0 0.2 g.p.h.
--
o YèS 0 No* Were all LLDs confirmed operational and accurare within regulatory requirements? j
o ):ts 0 No* Was the testing apparatus properly calibrated?
_.
DYes 0 No* For mechanical LLDs, does the LLD restrict product flow jf it detects a leak?
I 0 NJA
---
0 YèS o No* For electronic LLDs, does the turbine automatically shut off if the LLD detects a leak?
o N/A
0 YèS o No'" For electronic LLDs, does the turbine automatically shut off if any portion of the monitoring system is disabkd
o NíA or disconnected?
0 Yes 0 No* For electronic LLDs, does the turbine automatically shut off if any p0l1ion of the monitoring system malfunctions
0 N/A or fails a resI?
--
0 \'èS 0 No* For electronic LLDs, have all accessible wiring cOIlIlections been visuaJly inspected?
0 N!A
CJ YeS 0 No* Were all items on the equipment manllfactur~r's maintenance checklist completed?
-
h 1 r
,,- in flu; Section H, below, describe how and when these defici~ncies were or will be corrected.
fL Commems:
------.
..--,....--.'--
._--,----
-....- ---,----~~- .-
-- ~-'..- ,-------,
".. "..- --,---~
.... --'----,- -"
----. ,.---
Pa~e 3 of3
03/U I
, '.
I\'lO/iilOfiug SYSlem Certiflcation.
Silè _-\ddn:ss: ~ t-tAJ Jù yCs
UST Nlonitoring Site Plan
A ({l~) .2 (.¡ 11- '{3u dv(. OI.U~~~ (3LtD -/l4I.Æð1'l>'ñ1Øt.n~ G/
[:
¡
j
I
i
I
¡
¡
¡
¡
,
¡
I
I
I
I
¡
!
¡
¡
¡
I
¡
¡
¡
¡
¡
I
y"':
. . . .
. ...
''6 '
'-. : \
~
:~I
. . . .
. . . .
~'
ÇJ
o
c.
, . . , , '5u¡' . 5'6 ~
, 9t ('I ¡oJ !'- . . ~t? . ~. .
'/).IJ tl
tJo.þ\
~ '1t:
u:~. . (,Cp~-íl1
.... '~jL
~
:~ú,~:
. VtJtfoi\
tJ ço:tJ:
. . . .
b'~~J
:A:AJ(V:è,(~ ?1Ae?£:
. . . S£¢.D~. . . .
DaLe map was drawn: -/f2J JLJ V 'f
Instructions
11';. (\Ll already have a diagram that shows all required information, you may include it, rather than this page, with your
Múnitoring System Certification. On your site plan, show the general layout of tanks and piping. Clearly identil\
lO('~H:iüns of the following equipment, if installed: monitorlng system control panels; sensors monitoring tank annular
Spè1LèS, sumps, dispenser pans, spill containers, or other secondary containment areas; mechanical or electronic line kak
dèlc.:<.:wrs; '<ìnd in-tank liquid level probeß (if used for leak detection). In the space provided, note the date this Site Plan
\\ù'; prepared.
Page _ ef _____
(15/1111
· '.
MONJ¡TOR CERT. FAILURE REPORT
SITE NAME:
A (Z.c.o
DATE: IO-&-<Jl.t
CITY:
TECHNICIAN:
SITE CONTACT:
ADDRESS:
THE FOLLOWING COM?ONENTS WERE REPLACED/REPAIRED TO COMPLETE THE MONITOR
CERTIFICATION TESTING.
LIST OF PARTS REPLACED/REPAIRED:
REPAIRS: A.)(jAJ"Æ
LABOR: AJðAJ~
PARTS INSTALLED: ¡U () JJ 1£
RightFax
9/29/2004 7:16 PAGE 001/002 Fax Server
..
. '",
09127/2004 14:35 6613920621
PAGE iU/81
.COpy REQUESTED PLEAS~
FAX(ó61)392-0621
CITY OF BAKERSFIELD
OFFICE OF ENVIRONMENTAL SERVICES
'~OO '"r.t2l..lX'TOrl Ai.e. -~V<SF t£.Lb 1 Ut
~ ttølOÜ.g'5~..-õnì~ .
APPLICATION TO PERFORM
FUEL MONITORING CERTIFICATION
FACILITY ~)ö""t\nis AY(l' 0 I
ADDRSSS d ~ l d... ßu..Lik("'})~~ Y'I~ ~LtrI~_::..ß~~F~rt£CD, c-4
OPBRATORSNAME ~Jð~V\'1
OWNERS NAME l l.o~"Vì V\ '-/
NAME OP MONITOR MANUPACTtJRBR "'é C? 1"1~ 1<;- Q~ "'Ç'I"'" - :'""rL ~ - ~~
. .
DOBSFAcn.rryHAVEDISPBNSBRPANS? YBS~ NO_
I .
'.' .
TANK 4i
I
-z..
~
VOLUME
0,000
If? t OOÖ
IO/ODO'
CONr.BNTS
U nL -'B ..,
lJ V'I ( -£.'4
. pl'Z1ëJ'y\-') '-: '
, .
I
i "
j .
NAMB OF mS11NG COMPANY _)ICH ENVIaaNM1!:N~AL
CONTRAcrORS UCBNSB., 90-1072 I
NAME ck PHONE NUMBER. OF CONTACf PERSON JAMJ:~ ~I~
DA'Œ "TIldE -œsT IS TO DB CONDucœp~'to/ 0 ~ Ó ~ ..
i' .
J. jl~
~ .
¡ .
. ~~Q;;;;;1
APPROVBD BY
'iIB1fi
/ DATE. .
. i
~ '
. ~¡.L IY1 ctw
SIO ATURE OF APPLICANT ¡
."
'-