HomeMy WebLinkAboutABOVEGROUND TANK
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RICH ENVIRONMENTAL
5643 BROOKS CT BAKERSFIELD, CA. 93308
OFFICE(661)392-8687 & FAX (661)392-0621
ACURITE TM PIPELINE TESTER
Precision Product Line Test
TEST RESULTS
Test Date:l0/ll/04
BILLING:MEMORIAL HOSPITAL
420 34TH ST.
BAKERS FI ELD, CA
SITE:MEMORIAL HOSPITAL
420 34TH ST.
BAKERS F'I ELD , CA
PRODUCT PRODUCT MECHANICAL MONITOR
PRODUCTS LINE TEST LEAK DETECTOR LEAK DETECTOR
DIESEL -.OOO-PASS N\A ANNULAR & SUMP
DIESEL VISUAL FAIL DO TO STRIPPED FIBERGLASS FITTING IN PUMP ROOM
OMMENTS
A precision test was performed on product lines at the above location
using the ACURITE TM PIPELINE TESTER. I have reviewed the data produced
in conjunction with this test for purpose of verifying the results and
certifying the product line test systems. The testing was performed in
acorrdance with AES protocol, and therefore satisfies all requirements
for such testing as set forth by NFPA 329-92 and USEPA 40 CFR part 280.
The results of testing are shown on the following page. Included with
the report are reproduction of data compiled during the test which
formed the basis for these conclusion. This information is stored in a
permanent file if future verification of test results is needed.
I declare under penalty of perjury that I am a licensed tank tester in
the State of california and that the information contained in this
report is true and correct to the best of my knowledge.
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C~~~~-1072
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RICH ENVIRONMENTAL
5643 BROOKS CT BAKERSFIELD, CA. 93308
OFFICE(661)392-8687 & FAX (661)392-0621
ACURITE TM PIPELINE TESTER
WORK SHEET
DATE: lð-IJ-òu
--~--
wjO#:
Fac..:ili ty Name: n~~/-1-L
f7()jP J 7'" '-
Facili ty Address:!:fM .Jc.¡TIi-' .IT
ß~A::$(l..1;'''L 0 .I ~
Product Line Type (Pressure J Suction I Gravity): f,(.)t.:r (1"'f.,)
Pump Manufacturer: .JJ !IÁ
Isolation Mechanism: FeJ"T ~v£
PRODUCT
TEST
PRESSURE
(PSI)
VOLUME
RATE
(GPH)
RE SULT
PASS/
FÄÍL
o
I ~oæJ
()M...
I certify that the above line tests were conducted according to
the equipment manufacturer's procedures. The results as listed are to
my knoh'.ledge "Crue and (;orrect.
The test pass/fail is determined using a threshold of 190 ml per
hour (0.05 GPH) rate aL 1 1/2 times working pressure or 50 pSl which
ever is greater.
St.ate License: # 90-/0'1z
MFG. CERTIFICATION: # 60a.LT
VIScM-L ~E
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MONITORING SYSTEM CERTIFICATION
FDì' U$e By All Jurisdictions Whhin ¡he State of California
,"II/(/¡oriry Cired: Chapfer 6,7, Healrhand Sajèry Code; Chapter 16, Division 3, Tide 23, Calijòrnia Code ofReguk¡¡ions
This IOn1ì l1ìllSl be. lIse.d w document œsting ?ffid servicing of monitoring equipment. A separate certification or re.pon must be prepared
.tor ç,h:h moniwring system concrol panel by: me technician who performs the work. A copy of this form must be provided to the tank
S)S<ëlll owner/operator, The owner/operaror musr submir a copy .of rhis form to the local agency regulating UST systems wÜhifi 30
Jays uf [¢sr dare,
A. Gcílërallnformation
fa(;ìlhy Name: rJþn(/ 1t14L- 1,Jf!/{)P 1'r-4-'L
SiTe A,ddress: !:1).o6 :) 4 TU' ~ T
FaL'Üìry Comac[ Person: (2L>C1 pf
lVbkè..l\ludel of Moniroring Sysrem: ðw~..v5
City: ß,ð-I(.$ ,SF'1 F t,f)
Bldg. No.:
Zip: '33å J
Contact Phone No.: ( )
Fl':¡--J. Date of Testing/Servicing: JtL/1L-/~
. (fJ fl..fJJQf¡ ,
B. InveiltMY of Equipment Tested/Certified
Cbc,'I; r1JC "J!.Qr0fJj'i~¡è boxes ro iodjc¡ IC s ccilic c me/lI ins JccIcd/sen'iccd:
r ,- - --
Ii T:ÌlÌ1LiD:_-RbL-~
lOin-LInk Gauging Probe, Model:
I ~ A.i1nular Space or Vaulr Sensor, Model: ~J ((J0AI/1Jv,
II fJ P..iPj¡~g SLH1~P, / Tn:nch Sensor(s), Model:
o FlU Sump Sensor(s), Model:
I 0 1\1èdl,ulical Line Leak Derèctor, Model:
o LkL'l1\\JlJL' Lwe Leak DeleClOf. ModeJ:
I OLin!;: OvediU / High-Level Sensor. Model: _
_ 0 ºrhèf (S è~ uj meJlC ry e and model in Sþcrion E on Paoe 2 .
'Lwk lD:
o lll-Úllk Gauging Probe, Model:
o A¡un¡!ür Space or Vall ¡ Sensor, Model:
o PjpÜlg Sump / Trench Sensor(s). Model:
o FiJJ Sump Sensor(s), Model:
I 0 l\lèL'h,wìc,d Line Leak Derecmf. Model:
o EkclfûUi.:; Line Leak Derecror, Model:.
II 0 -LUlk Ol-aml J High-Level Sensor, ModeJ: '
\lll_º-º~!lèJ'lSQeCir'Y eljuipmenr r)fpe and model in S~crjon, Eon Pa 'e 2 .
I Dis¡Jtnser 1D: ~
II 0 Disptusèf Conrainmenr Senso1'(s), Model: .
il 0 S!lèJr Valw(s),
i~_DjS'p~Jl~èr CO~1lainmem Floar(s) and Chain(s),.
'I Dispenser 1D:
I 0 DìspèJbCr Comainmenr Sensor(s), Model:
II 0 ShC~ΠValve(s),
11_ CJ Qi~pë~!Sèr Comainmenr FloJJ(s) and Chain(s), .
Dispènsd 1D: '
1'1 0 l?ispdbè1' Conminmenr Sensor(s), Model;
.1 0 ::-;hë:U- V üJvè(S),
LOpisQ.èIlSer _Con;ainmèJlC FJoar(s) and Chain(s),
'lfrl1è ÙcilÌly conrains more ranks or dispènsers, ¢opy rhis fonn,
Tank ID: D.{ L-1ÆAq:T'
o In-Tank Gauging Probe, Modd:
j/J Annular Space or Vault Sensor. Model: """'£(JJ 'tfli:lUl/!!fi)__
o Piping Sump / Trench Sensor(s), Modd:
o Fill Sump Sensor(s). Modd:
o Mechanical Line Leak Detector. Model:
o Elecrronic Line Leak Delecro1'. Model:
o Tank Overfill I High-LeveJ Sensor. Model:
o Orher (s eci', e ui mem t e and model in Section E on Pae ::n, _
Tank ID:
o In-Tank Gauging Probe, , Modd:
o Annular Space or Vault Sensor, Model:
o Piping Sump / Trench Sensor(s), ModeJ:
o Fill Sump Sensor{s). Model:
o Mechanical Line Leak Detector. Model:
o Electronic Line Leak Detector, Model:
o Tank Overfill / High-Level Sensor, Model:
o Other (s èci e ui ment ' e and modèl in Section E on Pa' e 2),
Dispenser lD:
o Dispenser Conrainmènt Sensor(s). Modèl:
o Shear Valve(s),
o Dis enser Containment Float(s) and Chain(s).
Dispenser ID:
o Dispenser Containment Sensor(s). Model;
o Shear Valve(s),
o Dis enser Containmem Float s) and Chain s).
Dispenser ID:
o Dispenser Conrainment Senso1'(s). Model:
o Shear Valve(s),
o Dis enser Containment FJoat(s and Chain(s),
Include information for every tank and dispenser at the facility.
C. CerÜÏicatiofi -1 cerrify tbat the equiPlflent identitied in this document was inspected/serviced in accordance with the manufacturers'
guiddiui:s. Attacbed to this Certiticatio~ is informacion (e.g. rnanutacturers' checklists) necessary to verity that this information is
':ùffè<:C aud à Ploc Plan showing the layou~ of mouitoring equipment. For any equipment capable of generating such reports, I have also
_, ;¡¡¡¡¡¡;h¡;d ¡¡ cop~' o~· tho e report; (check all (h~( appM: D system. ~et-up D~lar~eport
L;L'llmctan Name tpnm): t.Y4'U ¡./I..6¡ol{J SIgnature: _~~
Cènifi.carion No,; (/¡jfl- ~S-... JJ 7-' . License. No.: 61/D40- # ~'p9850
I'èsÜng Cumpany Name: RICH ENVIRONMENTAL Phone No.:(661 ) 392-8687
Silt.r\ddrtss: t/J<J .1IJTtf <T g4J(.þ-~¡:;IJ¿,rJ/ Cr1- 'JJ~/ Date of TestinglServicing: /dIll I_~
Moüiwring System Ceni1ïcatÍoß
Page 1 of3
03/01
ï ~ :.i
n. iZèSu.hsof Testing/Servicing
SoÙ\\ J[¢ Ver:>Íonlnstalled:
. CÙii1pkr¡; dìèfollowinu checklist:
lfty èS 0 No" Is the audible alarm 0 erational?
'Q9 \~ U No'" Is the visual alarm 0 erational?
\'ö 0 No" Were all sensors vislla:Il ins ected, functionall tested, and confio11ed 0 erational?
I 50 Yd 0 No" Were all sensors instaped at lowest point of secondary contairunent and positioned so that other equipment will
not imertère wirh their ro )et" 0 eration?
CJ Yd 0 No'Í' If alarms are relayed ro a remote monitoring station, is all communications equipment (e.g. modem)
. N/A operarional?
U I{ èS 0 No'" For pressurized piping systems, does the turbine automatically shut down if the piping secondary containment
Ji!l' N/A monitoring system detects a leak, tàils to operate, or is eleco·ically disconnected? If yes: which sensors initiate
posirive shut-down? (Check all that apply) 0 Sump/Trench Sensors; 0 Dispenser ContailU11enr Sensors.
Did IOU confirm osit.ive shut-down due to leaks and sensor failure/disconnection? 0 Yes; 0 No,
~ '.:è5 0 No" For tanlc systems th~t utilize the monitoring system as the primary tank overfill warning device (i.e, no
o NiA mechanical overtìll pr:evention valve is installed), is the overfill warning alarm visible and audible at the tank
fiU oim(s) a.nd 0 erarino )ro erly? {fso, at what ercent of tank ca a.ci does the alarm triuùer?"''' 'Yo
o Y èS'> ;a No Was any monitoring equipment replaced? If yes, identify specific sensors, probes, or other equipment replaceJ
and Jist the manufactUfer name and model for all re lacement arts in Secrion E, below.
U Y è:,;'> ò«' No Was liquid found inside any secondary containment systems designed as dry systems? (Check all fhat apply) 0
ProdLlcr; 0 Water. I~ es, describe causes in Seerion E, below.
)Q Y è:> 0 No'Í' Was monitorino s stenl set-LL reviewed to ensure fO er settinas? Attach set 1I ¡cable
~ YeS 0 No" Is all monitorina e ui mem 0 erational er manufacturer's specifications?
" In S¡;c(Íou E below, describe how and when these deficiencies were or will be corrected.
£. CÜiHmenIS:
.. -_.._~---.--.--.-
---,'-- .-.--,...-.,----
---...-.--" .--
___,_ .....0__' ._______ ______.
--_._...-- ------.--. .--
,.-_."--- ..------
.-.--.-.--. ---- ------
---_.-.--- ---.
----.-- ------
___ -'--_'-_."0
.n_____
.-.-..--.--.--
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Page 2 of 3
03/01
¡ ..r.. _....
F. lil-'i\mk Gauging J SIR Equipment:
~ Check this box if tank gal¡ging is used only for inventory control.
a Check this box if no tank gauging or SIR equipment is installed.
This sècrion l1.1.ust be completed ifin-tanlc gauging equipment is used to perform leak detection monitoring.
CÚii'.Q.!01i:: {hi:: following checklist:
0 , 0 Has all input wiring been inspected for proper entry and termination, including testing for ground faults?
'\ ¡" :. ~ No'"
ll.,..~
--
0 \'c:s CJ No'" Were all taruc gauging probes visually inspected for damage and residue buildup?
U Yc's 0 No* Was accuracy of SyStel)1 product level readings tesred?
O'Ús I 0 No" Was accuracy of sysrem water level readings tested?
~-~
o lèS 0 No" Were aU probes reinstalled properly?
e---
0 y. 0 No* Were all irems on the equipmenr manuíàcturer's maintenance checkJist completed?
c"
-
., Ii! die .s¡;~rion H, below, describe how aud when these detïciencies were or will be corrected.
G. Lint Le.ìk Detectors (LLD):
~. Check this box ifLLDs are not instaJ1ed,
c
f II
h kl' t
Olli¡)kt<: rile Û owwg c ec' IS :
o 'l èS 0 No* For equipment start-up or annual equipment certitì.cation, was a leak simulated to verify LLD performa.t1ce?
0 N/A (Check all thaI apply) Simulated Jeal\: rate: a 3 g.p.h.; a 0.1 g.p.h; a 0.2 g.p,h.
DYes 0 No* Were all LLDs confirmed operational and accurate within regulatory requirements?
o 'Its 0 No" Was the testing apparatus properly calibrated?
DYe's o No* For mechanical LLDs, does the LLD restrict product flow if it detects a Jeak?
ON/A
U )ièS o No* For electronic LLDs, does the rurbine automatically shut off if the LLD detects a leak?
ON/A
-- For eleen-onic LLDs, does the turbine automatically shut off if any portion of the monitoring system is dis'1bIed
o '{èS o No*
I o N/A or disconnected?
0 Yes 0 No" For electronic LLDs, does the turbine automàtically shut off if any p0l1ion of the monitoring system malfunctions
0 N/A or fails a rest?
U Yes 0 No" For electronic LLDs, have all accessible wirillgconnections been visually inspected?
0 N/A
0 \'èS 0 No" Wère all items on the equìpmènt manufacturer's maintenance checklist completed?
" in ,he secÜoll H, below, describe how and when these deticie~cies were or will be corrected.
1-1. Com,mems:
---....----.----.
----,..------
------
- ..---------
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Page 3 of 3
03/01
:-.1'- .... ..
Mùnílùring Sys[em Certification
SiT;;; Addn:ss: __ 'J.t)
UST lVlonitoring Site Plan
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Da¡e map was drawn: -.A2J 1/ 1&17
Instructions
If yùu alrèady have a diagram that shows all required information, you may include it, rather than this page, with your
Monitorjng Sysœm Cerritìcation. On your site plan, show the general layout of tanks and piping. Clearly identify
lo(;ürio!ls of rhe following equipment, if installed: monitqring system control panels; sensors monitoring tank annular
spacès, slImps, dispenser pans, spill containers, or other secondary containment areas; mechanical or electronic line leak
dèrè(;[Ùj's; and in-rank liquid level probes (if lIsed for leak detection). In the space provided, note the date this Site Plan
\\¡l'; prep:lrèd,
Page ~Of~
05/00
09/27/2004 14:36 6&13928621
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*COpy REQOEST~D ~~BAS£
FAX(~61)392-0621
CITY OF BAKERSFŒLD
OFFICE OF ,ENVIRONMENTAL SERVICES
·';00 7X2£..l.Xmn ~ ·-~R5rÆ.Cl), c..A
~ (~O.g~~.,-';Hì,1
APPLICA TIO.N TO PERFORM
FUEL MONITO~NG CERTIFICATION
FACIUI'Y rvîL.f'V1(")~¡41 ",J:1cc:;.p rT1'-\-l
ADDRBSS J.t:J..D;5 ~ 11+ ~~. .
OPERATORS NAME Cf& )
, OWNERS NAME ~ 'ff(.J . L
NAME OF MONITOR MAN'UP,AC'rUlU3R-
, '
DOES PAC11lTY HA VB DISPBNSliR. PANS?
I
(ÖB\.(Bi<~V\Fl ~j4-
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Qu)E{) -{'J) Q(\)()þ ~-~
YBS_ N0H
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TANK ,
,\
VOLUMB
1(2,000
I () ¡oDD
CON'I'BNTS
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NAMB OF TBSTlNO COMPANY }U~H ENVIRD~f~NT~L i ; ..
CON':tRACTO~ UCBNSB II ~O-l 072
NAMa Ii; PIIONENUMBER. OF CONTACT PERSON .;TAKES RIça 1661 );39~-.1587
DA11!.tTJMETlmISTOBECUNDur:rsp 1~t:;f - ~;~~T
,i,(~a~i() o/~ï~i ~ Ik~ ,¡ ·
APPltOVE!>BY DÁ:m" SIONATURBOFAPPUCANT :
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S\'v R.CS, January 2002
Page -L of _~_h
Secondary Containment Testing Report Form
T11 is jÒrm is imended for use by controctors performing periodic testing of UST secondary contoinment sy~tems. US(l thil
appropriare pages ofihisform to report resultsfor alJ componems tested. The completedform, written test procedures and
p¡,jmoulsjì-om Jests (if applicable), should be provided to f114facility awnerJoperator for submittal to the local regu/at~ agency.
1. FACILITY INFORMATION
W Facihty Nii.ll1è~ ~I .
1¡~I~;:iiiLŸAdd.ress: 4JC) ..Jo/T# .(/ t!.
I Facility Contact:
¡~------,
Il--l?::::..!-oç<ü Agency Was Notified ofTestiJ.lg: ~~ '
_N~l~C' of Local Agency Inspector (ifpresent during testb'lg): ~ð~
.,
rS~~;l~p~~;l~~m~: R.I~~ ENVIRONMENTAL
f"'dUÜCian Conducting Test: ey.+t,J M4$;...J
\ _.C redèuÚa!s: I». CSLB Licensed Contractor o SWRCB Licensed Tanlc Tester
Li¡,;ense Type, C611 D40 .., L¡c,,~e Number: 809850
F"..··....,,~·..,."I'e.:;·~·n.....:.a .")~>.......
... "-II' . ,,_ I'~ ,I_! ~ t·,. . M._rer Training
1------ Manufacturer COt:l;]DOnentC s) Date Trainín2 EXDires
INCON INCON ~S-STS 8/04
1-'--'--- .
11--_____
I
~ ....-- -.-,. - .
2. TESTING CONTRACTOR INFORMATION·
I
10
1--
IQS
1---
r
r-
~--
I¡-
\\'=~
l-
Component Pass Fail Not Repairs Component Pass Fair Not Repairs
Tested Made Tested Made
-..
~~Ül._ P,/,L. ðOlx ! rJ 0 0 0 0 0 0
Let FII,(, I\w}C j 0 0 '0 0 0 0 0
0 0 0 0 0 0 0 []
-------
0 0 0 0 0 0 0 0
-- "'.i,'·" 0
0 0 0 0 0 0 .D
-----..----,-. 0 0
0 0 0 0 0 0
.----- 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0 0
_______H. 0 0 0 0
0 0 0 :0
-- 0 0 0 [)
0 0 0 .0 .
_..~_. 0 0 0 0
0 0 0 0
- 0 0 [) 0
0 0 0 0
. --. -
3. SUMMARY OF TEST RESULTS
if hydrostatic testing was perfQ.ffiled, describe what was done with the water after completion of tests:
~, ~.
RECYCLE AND REUSED
.-.-----..
CERTIFICATION OF TECHNICIAJ~ RESPONSIBLE FOR CONDUCTING THIS TESTING
lì.} tlte best of my Imow/edge> tile acts stated in this dOCU1J!~ll are accurate and infull compliance with leg"¡ Ttlqli¡~is
~
Date: /11-/ J4"f
T èchnician' s Signature:
~.-.. '" ¡
::; w tZCß, January 2002
Page -..J:of _J_,
9; SPILL/OVERFILL CONTAINMENT BOXES
I: i;a.C.iÙ;y is Not Eguipped Wi.th Spill/Overfill COl1tainmentBoxes 0
I: Spill/Overfill Containment Boxes are Present, but were Not Tested 0
r-:¡~[ 1vï~.hod ì).~veloped By: 0 Spill Bucket Ma.nufa.çt\U-er
__ _.__ ____,______ 0 Other (Sp¡çâfy)
Tes[ IVlèthod Used: 0 Pressure
o Other (Specíjj~
----~_.-._-_. .
'['(:$[ EqLÜpmènt Used: INCON TS-STS
[~;~;·,';""';7<71:':;;~Wt;;
~~t:~~:J"C
1_,-..._------,
I \Vair time between applying
I prtssureJvacuum/water and
! sw.rÜn~ test:
1- --- --,----=-
feST Sta.rt Time:
iI Industry Standard
o Professional Engineer
o Vacuum
S Hydrostatic
initial Reading (R¡):
Tesr End Time:
Final Reading (RF):
Tesf Duration:
I Ò1<mge in Reading (Rf"'R¡):
Pass/Fail Threshold or
Criteria:
Test Result
"I'
. - . pment Resolution: . 000 in.
..
c.r-
SpiU Box #
Spül ox #
3d ~ vv
.000,-eJ
J4 Pass
.v
. ~ø;.v
.~,'Ú
o Fail
.2' Pass
_OOJ.. 'U
o Fail
o P~UiS
o Fail
OPus
o Fail I
__çíÞmments - (include information on repairs made prior to testing. andrecommendedfo/lo'W--upfor jQiJedtestsl
---.-----.----.
_.._...._-----~
-.- -...-----.---
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