HomeMy WebLinkAboutMITIGATION 10/22/2004
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OCT. 22. 2004 11:08AM USF Bestway NO. 5388 P.2
MONITORING SYSTEM CERTIFICATION
Fo,. V$(l By All }u"'isdictio"~ Wirhfn the: SeattI ofCaiiforn;a
AuthOficy Ciled: Chapter 6.7, HeaLth and Safecy Code; Chcpter 16. DivisioM 3, Tirle 21. Ca/¡fo'tnia Code of RegulalloT15
This form mUSt be used to document testing and servicing of tIlonìtoring equipmcrtt. ð.. se,p6~te cenification or reDort must be cnroarec
for each moni!orinp.: svstem control Danel by the technician who performs lhe work. A copy Dftb..is form must bc provldt:d 10 the ¡¡u¡J
system owner/operator. The owner/operator must s~bQ1it a copy of thii3 form to me local agency regulating UST S)'~na w1thin 3(
days of test daCe:.
A. General Information
Facility N&me: ~ ~~~
Site Address: ~Ol t..\'S~ Mk\6 ck
F3Cility Contact Pen;ol1: gf I \A.¡\. L..ov\.Ö
MaktlMode.J ofMonitOrUlg Systew: 9&!brlN~
_ Bidg. No.:
City: gA~....r~?;I"Jc-l Zip: ~::n3
Contact Phone No.: «(,¡v I ) ~~- 1;r]D$
a f<-~iC.l n:::r Date ofTe:>riDgfSerJicing: J..!U Z2-/ ~
B. Inventory of Eqn.ipment Te5ted/Certified
Cb"1t W I" to . tc boxa to Ùldio::ate . c e ui me¡¡elÞs a:tedl.erviea:l:
T'1nkID: or~
iii In-Ttu:1k Gnug!ø.~ Probl:i. Model: M'u'-'
o AMular Spac¡¡o ot'Vault Sensor. Model;
Q Piping Sump / Trench Sensor\s), Model:
o Fill Sump Scmot(,). Model:
o Mechanical Line Leak Deteçtcr. Moò¢\:
tJ Electronic Lint: Leak Detector. Model:
o TaJ)/c OY'erfill / High-Level Sensor. Model:
o Qfb¡;c e uí t anQ 1IlCdcl in Sectioll E an Pa c 2 .
Taqk ID:
o In-Tank GaUe!ng Probe. M04el:
CI Annular Space- or ViUlt S=r. Model:
o PjpiD~ Sump I TmlCh Smsor(s). Model:
o Fill Sump Scnsor(s). Model;
Q Medwlical Line Leak Det¢Ctor. MOde!:
Q Elcctronic Line Leak Defector. Model:
D Tao.Ic: OvediU I High-LcVèl Sensor, Model:
o Other e u.i mco[ e and .!node! in Scc;liQn g on Pa c 2 ,
Tank ID:
o tn-Yank Gauging Pro~. ModeJ:'
o AnIlular Sp3/;1;: or Vault Sensor. Modçl:
0. Pipi:ng S\1IIlP / Trench ScnsOr(s). Mod~:
Q Fill Sump Scnsor(s), Modçl;
Q M~hanical Line Leak Detector. MorJel:
Q Eleen-owe LiDo Leak Detector. MeeSel:
o Tank: ~dilll Higb-Ltve:l Srosor. Model:
a Other eci i cnt c and modç[ iD Sectíon Eon Pa c 2),
Tuk m:
Q In.Tauk GaugiJlg Probc,. Model:
a Annula't' Space or Vault Sensor. Model:
o Piping Sump I Trench Scnsor(&}. Mod<;l;
Ô I'HI Sump Sensor(s). Madel:
Q Mechanical Line Le:Jc DetectDr. Mod/'òl:
a ElectroClÍc Line Leak DetcetOt'. Mode!:
Q Tnnk overf1n/HJgh-ùwe.l Sensor. Mod/'òl:
Q Othet ui øem e &ad modðl In Sec[ion E 011 P e 2),
Db:þensa- ID: D\s~ 11>:
tJ DispClUCr Conta1nmcnt $ecsor(s}. Model: Q Dispcnsër COl'J.tainmèi1.t S;:nSO!{s). Model:
o Shew Valvc{s). 0 Sh=c Val-vc(s).
Q Di cnsa Contninmcat PI 0 ¡:)' t;r Contllim"tlent F1
Di,penscr ID:' DispClStef ID:
Q Dispenser Coot¡LÌl1II1cnt S=r(s}. Model: 0 Dispenser Contllimnent Sensor{s}. Modct;
Q ShC!lI'Vu.lvc(s), CI Sb.earVdvc(s}.
o D' !lose¡ Containment Float s ÐI1d Chain(s , 0 Di cr ContcinmcuLflo s and Ch' ~,
Dispcasor J:D: D¡'pensOI' ID:
tJ Dispcn6c:r Contahünent Soosor(s). Model; 0 Di:¡pcllSQr ContaÏm1\ent SQ1SOr(s), Model:
Q Sheø¡- Valvc(s). Q Shear Valv~s).
om r Containn1çnt PI 5) and s . ,Q . ensa' Contaim:n.cTrt Floa: S 'aDd Ch3!n(s).
"If the: facUlty con1aÏDs ¡note tan.Ia: or ~<;<$, .~y Ibi$ fonn. Include infQW1B1ÎOQ for e~ tank and dispcnst:r at !be &cility,
c. Certification. I Ctrtify tf at the eq,-Ð.ipØ1ent ldentiDed in this document WI.!! inspcdedJservi
guidclille:¡. A~êhed to thí:t Certification is inror\tl.1.tlol1 (e.g. lU~ur....etur·cn' cJ¡~k!isb)
correct 8I1d Ii Plot Plan JDOwin't the layout o( ~OD tQriDg eqvipmènt. For any equi
attadted a ~øpy o(tbe report; (¡:b«k alllJcIZt ØPlJV): Q System ,et-up 0 A a
Technician Name (print); ~Ed McKee _ Signan¡re:
Certifjc.îQon No.:
TèSting CompBllY Name: _Tn-State Enviro~ _ ( .
Site Mdre¡ss: k1pl Ç.A.s- 'MDrI'\"- ~
....-
Liœn.se.. No.: ....,.......A738065
Phone No.{JóO~_95Q..0024
Date of Te~ting/Servicing; ) 0 I 1J..j !!+-
Page 1 00
031111
Moaltoríl,lg system Cert1ftcatioD
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OCT. 22. 2004 11: 09AM
USF Bestway
NO. 5388
p, 3
D. Results ofTes.ting/Servicing
SoftwiIIe Version Installed:
--
Com lete [be rolJowrDI!; ebcckJist:
I . Yes 0 No" [s (he audible- alarm ooeralioaaI?
Yes 0 No· Is the visual alarm 0 tional?
Yes 0 Nö" Were all scnsors vis\ID.1l inscccted, functionallv [BStcd. and cOlÛlmled 0 eraÜow.l? !
GI Yes I Q No" Weré :a.1I sCt1sors instaHed at lowest pomt of secondary containment and positioned so tha[ oilier equipment will .
nOt imerfere with tbeiT TO er 0 eruion?
CJ No· If alarms are rel3yed to a remote monitoring station. is all communica[ions equIpment (e.g.. modern) I
~~ .~~ !
o No· for pressurized piping systems, doæ the rorbine- aucomatically s.hw: dowu if tbe piping secondary comllinmenr i
It) NlA monitoring system d~t~cts a leak, fuil$ to ope.T.3.te, or is elec1!Ïcally di~connccted? If yes: which sensors initiate: !
positive shut-down? (Check ell thar app~v) 0. SwnptTn:nch Se¡uors; 0 Dispenser Containment Sensors.
Did ou confIrm ositive ShUt-down due to lea\cs and sensor failun:/disconnection? Q Ye~; a No,
No'" For [ank systems that Iltiljze the monitoring sy$1:em 2.5 !he primary tank overfiIl warnrog device (i.e. no
N/A mechanical overfill prevention valve Ï5 installed), is the overftl1 W4U"Uing alarm visible and. audible at the tank
fill oint(s and 0 CI4tÎn ro cd ? If so, at whm erCent of tank ca aci docs the: slann nie: er? %
W3.$ any monitoring equIpment replaced? If yes., identify specific sensors, probes, or ower equipment replaced:
and list Iilc m.a.nl.l.fucturer name and model for all n: Iacement arts in Section E. below,
W~ liquid found inside any secondary conw.im;!lent systems designed as dry systems'? (Check all chat apply) 0
Product; 0 Water. If es, describe causeS in Section E, below,
II Yes 0 No· Was moniIorin stero Stt- reviewed to ensure TO er sertin 57 Anach set u
.!liI Yes a 1'10* Is all monitoriD c u' ment erntional er m¡mufacturer's ecification,,?
.. 10 Sectioo E below, describe bow and when rhesè dencieucies were or will be corrected.
f
o Yes
o Yes
I
o Yes
l~
DYes"
æ No
DYes"
II No
E. Comments:
+.1
Pr'l~r
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P~ge 2 ofJ
1)3101
j
OCT. 22. 2004 11: 09AM
USF Bestway
NO. 5388
P. 4
F, In- Tank Gauging I SIR Eqnipment:
o Check this box ift1nk gauging is used on1y for inventory cootro\.
o Check this box if no tank gauging or SIR r::quipmeu[ is installed.
11ús section must be completed if in-tank gauging equipment Is used to perform leak detection monilodng.
Complete [ ~ folloWmg chec t:
g. Yes o No" Has all input wiring beeD inspected for proper entry and [ermination, including testing for ground fuults?
œ Yes Q No'" Were all tank g(J1lgî.ng probes visu.ally inspected for damagE: and residue buildup?
DYes (iD No* W ilS accurncy of system product level readings tesred?
DYes . Na* Wa~ accuracy ofsystern wator level readings tested?
-. Yes o No'" Were all probes reinstalled properly?
. Yes o No· Were !ill iœros on the equipment. numuw;ture'r' s maintenan~e checklist completed?
h
kIls
.. In tIre Section H, below, describe bow and when these deficiencies were or will be corrected.
G. Line Leak Detectors (LLD);
o C~eck rhis box ifLLDs are not instaHed.
c
Ii I
h
omPlcte tht 0 Jowin! c eckllst:
o Yes o No" For equipment stan-up or annual equipment certification, was a leak simulated to verify LLD performance?
o N/A (Check all that apply) Simulated leak ~te: 03 g.p.h.; 0 0.1 g.p.h; 00,2 g.p.h.
o Yes o No" Were all LLDs cOnÍ1IUJed operational and accurate within regulatory requirements?
o Yes o No'" Was the testing apparnws properlY-é8.libfil1ed?
o y~ o No· F or mechanical LLDs, does the tLD (~trict 'product flow if it detects a leak?
o N/A
a YE.S C No. .For ele.ctronic LtDs, does the rorbine auto!3)aticaIly såU[ off íf the LLD detects a leak?
o N/A
CJ Yes a No" For electronic LLDs, does the turbine automatically sbut off if any portion of the monitoring ¡ystem is duabled
a N/A or disconnected?
DYes a No· For electronic LLDs, does the turbine automatically shut off if any portion of the monitoring system ma.lfunctions
o N/A or fails a test?
DYes o No· For electz"anic LLDs, havo all accessible wiring co¡;w.ections been visually inspected?
o N/A
CJ Yes Q No" Were aU items on the equipment manufactlJrn's maintenance cb.ec)dist completed?
.. In the Section H. below, describe how and wben ~ese deficienci~ Were or will be corrected.
R Comments:
~ I _ ftvb l6 'Y\.Dt- I,vOÎ~.A\lt.tl - 12.e-c'O'MV\-~1 re.¡p(&clvtá
~~ u/ f:,~'-' \'t2~ ~ ~ ~"-~ \<-
.J ~.ill.- ~ (~V~ v\.v~ ( .v-0 .... ,~\, I v... u &~,.)
Page 3 Gf3
03101
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OCT. 22. 2004 11: 09AM
NO. 5388
MONITORING SYSTEM ÇERTIFICA TION
For U.se By All JzuiJ-dicrioY1S Wilhin rhe $JaJfl <>fCalifol7tia
Aurhoriry Cired: Chapter 6.7, Health and Safer¡ Code: Chaprer 16. [)ivtston; Tírle ;23, Calìfornia Code of Re~'atìons
USF Bestway
P. 5
This form 'Q1USt be used to docum.~nt œ:sting and ServicÛ1g of monitorinl?f equipment. A separoœ certt.fit1l.uolt ()[ remm..mu.'~. be: pn:J1areí
for each monitoriIJ.e: ~v!t(:m conl;rol panel by the [eclmician who petfonns the work. A copy of Ibis form must be: pl'ovi~d to tho tæ11
systen;¡ awuer/opc=rator. The owncr/openitor must :submit a copy of rlús ronn [0 the local agency rr:g1.1lati,ng UST ~tems within 3{
d;1ys of ~est da.ce.
A. General Information (/ ~ ( .
F~ci¡ìty Name~ (j~ç: , \,;)e~Þ-v¡
Site Ad~s: ,4:",o( L \oGA- V~( e 4.
Facility COIUaCt Pe~on: fj('\AA ~
Make/Model of Monitoring S~tem: L£.AJ.¿... A-w~
B. InventQry of Equipment Tested/Certified
CheQ.k 1!j! :r ro riate bG:I:tS to iadicatc 5 . c ui IIiðlt ÏDs ~s~niI:cd;
Blr;lg. No.:
Ciry: ~¿.\..\:.~{~CJ.. Zip; ~~S t1
Contac~ Phone No.: (~{ t.,;$~~ - .rrw3
<..rÞr-O~ Dat~ ofTesringlServioiD.g: ~fZ2. /~
Tank ID: D\~ Tank n>:
o In-Tank: Gauging Probe, Modol; Q ÍD-TII1lk Gauging Probe. Model:"
.. Annular Sp¡u:eorVlIlllt SCIlSOf. Model: [.,.A-t,..6 Q AnnulacSpace or Vault Sensor. Modcl~
f! PlpingSW11p/T¡'e,QchS~or(s). Model: ~- ~..... 0 Piping Sump I Tre.tlQ1 Semor(s) , Model:
o Pill Sump Scn.sot(J). Model: 0 Fill Sump Sensor{s). Model:
. Mechanical Line Leak: De~tor. Model: ~ J ""-J a Mechanical Line L=k Detector, Model:
Q EIcwcnJc Line Leak Detector. Model: [J Elcetl'onic Line Leak Dc~ectOr. Modl::l:
Q Ta1)k Ov=-filll Higb..L~1Iel Scmsor. Model: 0 Tank-Overfill I Hi&h·Levcl S.msor. Model:
IJ c' e I1Í màU c and model in Seàio.o E on P t 2 . [J Othc::r çc;' ui t e and ¡¡)Odd in Section E on Pa e 2).
'TlUIlt [D: Tuk ID:
a [n.TaAk GaugÙ\~ Probe. Model: a [n-Tønk Gauging Probe. Madel:
Q AnIrular Space or V¡w.\t SalSa'-, Model: 0 A,nnulur Space or V!I\1tt Sensor. M<XIcl;
o Piping .sump I 'I'n:nl:h Se,llS01'(s). Model: 0 Piping Sump I Trench Sauof\s). Model:
o FDl Sump Sc:nsor(s). Mode!: a F"tll Swnp Sensor(s). Model:
Q McchllllicaI Line Leak D~tor. Model: 0 McçluuUcal Line Leak Detcttor, Model:
o EJ.~trOnlC' Line LCIak DeteCtor. Model: a Electronic Wile Leak Detcctor. Model:
o TIlIIk OvcdiU I High-Le,",l Sensor. ~odel; Q Tank OvcrfiU I HighwLcYei Sensor. Medel:
o Olbcr (s co' u' 21aJt I!: and model in SectionE on P e 2, Q Other e' . nt e and xnodel in Section E on Pa It 2.
Ð~p~~lIr ID: O\~ DispeÐser D>:
. :Dlspcn8l!f Conϕnmc:nt SeD:lOr{s). Model: ~ Q DispJ;1)$er Containment Sensor(s). Modcl:
.. ShcwVa1ve(~). Q Sh=:r Valvc;(s).
. Dis œa- Co~ Q D' ';U$d' CODWnmcnt Fla s ~ Chaio(! .
])bpeas~ tD~ ~... ':>Þ'r. Dnpenscl' ill: -.:..
m"Dispenscr Containment Se~or(s}. Mode!: .for [J Dispenser COtJ,taImnem Smso¡(s}. Model:
I!'oI"ShcIIl'Valve(s). a Shc:arValvc;(s).
.It D" emcr Coo.tai!u'nent Q Di enscr ContainmeQ1 F10 s md Chain s .
Dbpenser ID: Dispemer D>:
Q Dispenser Contahim.ent SCDSQt(s). Model: Q Dispt::nSet' Con1!LÏnment 5=£(3). Mod~l;
Q Shear YuJ.ve(s). Q Shc:ør Valve(s).
QDis c:nser ConUlinmc:<Jt FIn s md s). C DI ~ Contsin:alcnt Float('s 'I1IId Clwln($ .
-lithe' t3cílity contains mon: wW or dÏspO'l1scn. copy tlüs. form. Include infurm~tl for cNer¡ W1k and W¡. cnse.r at thl: fucil.iry.
C. Certification - 1 certify tbat Ihe øtulpmeut ldoqt!.fæd in this document WI\S htspeded/,crvi:
guidelin~. Attsclrcd to tws CcrtillcatiOIl Js iDCo~tialJ (e.g.. mauufadur¡:n' chKkllst$) Dee $
col"tect and a Plot plan ~howing the layout of 1I1oQitoriug "quipment. For any .qulp ø e
attached a copy o{ the report; (chd rúI th4t øpply)! a System se~-up Q Alanø h t
TedwiciðJ1 Nome (pr-tnt); _Ed McKee Sígœturc,:
Certification No.;
o'Zr-o ~f?D
Llc~c. No.: _A73806S
Phone No.:C760_)_956-0024
Date o('Testíng/Servicing: tv I'lL / ðtr
resting Comp lIlY Naml:; _Tri-State Environmental
Site Address: ~l ~l~~ tv'-/hl1 e.
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P!l\l.C 1 of3
03101
Monitoring System Certif1cation
OCT. 22. 2004 11: 10AM
USF Bestwav
NO. 5388
p, 6
So!tw¡¡¡e Version [nstnlled:
D. Results ofTesti~g/Scrviçing
Com lete the follow!na checkJist:
II Yes D No" Is the audible ¡¡IMn 0 erational?
Yes Q No· Is the vlsuaI alarm 0 eraùonal?
Yes I Q No" Were aU s¢nsors visuaIl ins ected, fun.ruonaIl tesced, and confir.med 0 eralional?
y¢s 0 No· Were all sensors installed at lowest poim otsecondaTY comaímnent and positioned so (.bat otheT equipment will
!lOt IDterfere with their roper 0 e'alion? I
If alums are relaYM co a remore monitoring st.'\tion" ¡50 nil communications equipment (e.g. modem) I
operadolì.al'? i
For pressurized piping systems, does the nubiné automatically shut down if the piping secondAry containment
monitoring system dete~ ii leak, fails to operate, or is electrically disco¡wected? If yes: which sensors iniIiate
positive shut-down? (Check all rhat apply) 0 SumpfTrench Sensors; fill D~penser Com.ainment SeI1sors.
Did au con:fum POsitive shut-down due to leaks and 5~sor (aî1ute/diseonnectìon? ra Yes; Q No.
D No'" For tank systems that utilize: the monitoring system as the primary tank overfill warning device (i.e. no
fJJ N/A mechanical overfill prevention valve is Installed), is the overfill "vm-ning alann visible aud audible at the tank I
fill oin s and 0 eratin ro ed ? If so, at what ercent of tank cauaci does the alarm tri et1 %
Was my tnonitoring equipment replaced? If yes, identify specific sensors, probes, Or oilier equipment replaced I
and Ii~ the manufactUrer name and model for all r laC'ement arts in SecEioc. below.
W~ liquid found inside any secondary containment systems designed i:IS dry syStems? (Check all rhat apply) fa I
Product; 0 Water, If es. describe causes in Section E, below.
~ Yes 0 No· Was moJJ.Ítorin stem SCt-U reviewed to ensure 0 er set!ÎD 51 Attach set u
. Yes 0 No* Is aU motÜtorin e uiÐment eœtlona! e.rmanufacturer's s eciñca.Ùons?
... In Section E betow, describe how and wlien these deficieneies were or wilt be correcled.
DYes
a No'"
Ila 'N/A
o No"
o N/A
" YèS
Q Yes
DYes'"
I! No
\ I
¥ GI Yes"
o No
E. Comments:
-
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Page 2 00
OJ/In
·
OCT. 22. 2004 11: 10AM
USF Bestway
NO. 5388
P. 7
F, In-Tank Gauging / SIR Equipment:
o Check this box: ¡frank gauging (S IIsed only for inventory comrol.
.. Cbeck this box if 110 tant gauging or SIR equipment Is ÏßstaUed.
This section must be completed if in-tank gauging equipment is used to perform leak detection monitoring.
COnlolete the ro owiDI! checklist:
Q Yes o No· Has all Î1lp~t wiring been inspected for proper enuy and termination, inc!uèi.ng testing for ground faults?
Q Ye-s D No" Were all tank gauging probes viiually inspected for damage and re~ídue buildup?
Q Yes o No" Was accuracy of sy~tC1Il prodllct level re!.dings tested?
Q Ye.s d 'No'" Was accuracy of system water levEd rea~gs tested?
a Yes o No· Were all probes rcinsu!lcd properly?
Q Yes o No· Were all items on the equipment manufacturer's matntcI1J!Ilce checklist completed?
11
* In the S;retion H, below, describe how and when these deficiencies wer~ or will be corrected.
G. Line Leak Detecton (LLD):
Check th.i.s box if1...LD s are not installed..
ComDlete tbe following chcC'kljst:
I Yes o No· For equipment stan-up or annual equipmen~ certÜicntion, wa.!! a leak si.mulatcd to verify LLD perfom13I1ce?
CJ Nt A (Check all that apply) Simulated leak 111[0: II( 3 g,p.h.,; 0 0.1 g.p.h; 0 0.2 g.p.h.
.. Yes Q No" W ßrE: all LLDs conflnned operational and aCC\1nte within r¡;gu!atolj' requirements?
Q Yes 0 No· W85 the testing apparatus properly.cal.ibtated?
.. Ye:; o No·, For mechanical LLDs, does the LLD restrict product flow ¡fit detectS a. leak?
o NtA
íJ Yes o No· For electroDjc LLDs, does the rorbine automatically shut off if the LLD detects 11 teak?
IJ NtA
o Yes o Ne¡1& For electx'Ðnic LL.Ds, does the tUrbine automatically ~bùt off jf any portion of tho moníl.oring system is di~abled
D N/A or disconnected?
CJ Yes a No· For electr"onic LLD$, does the turbine automatically shut off if any portion of the monitoripg systew malfunctions
(II N/A or fails a. test?
Q Yes o No" For electronic LLDs, have: all accessible wiring connections b~ visually inspected?
(!II N/A'
.. Yes o No· We¡;e all itews on the equipment manufacturer's IDàintenance checklist çomple:ted?
Í( Io thè Section S, below, descrtbe how and when tbese deficteDcies were or will be ç:one:cted.
H. Comments:
.c,.. ,.
Page 3 of3
03'01