HomeMy WebLinkAboutUNDERGROUND TANK
FACILITY NAME~~S~e:.\d 111~W\oi'þ.)~· ~IINSPECTION DATE
*20 ~q\''''' ~
Section 2: Underground Storage Tank~ Program
CITY OF BAKERSFIELD I?IRE DEPARTMENT
OFFICE OF ENVIRONMENTAL SERVICES
UNIFIED PROGRAM INSPECTION CHECKLIST
1715 Chester Ave.. 3rd Floor. Bakersfield. CA 93301
II/gþf-
.
o Routine E' Combined 0 Joint Agency
Type of Tank D~ F
Type of Monitoring (1L1'Y\
o Multi-Agency
Number of Tanks
Type of Piping
o Complaint
1-
Dit\)F
ORe-inspection
OPERA TION C V COMMENTS
Proper tank data on tìle X
Proper owner/operator data on tìlc ~
Pennit fees current ~
Certification of Financial Responsibility X
Monitoring record adequate and current Y..
Maintenance records adequate and current \(
Failure to correct prior UST violations )(
Has there been an unauthorized release? Yes No Y-
Section 3:
Aboveground Storage Tanks Program
AGGREGATE CAPACITY
Number of Tanks
TANK SIZE(S)
Type of Tank
OPERA TION Y N COMMENTS
SPCC available
SPCC on tìle with OES
Adequate secondary protection
Proper tank placarding/labeling
Is tank used to dispense MVF?
I f yes, Does tank have overfì lI/overspill protection?
C=Compliance
V=Violation
Y=Yes
N=NO
White - Env. Svcs.
Pìl1~ - RlIsincss Copy
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RICH ENVIRONMENTAL
5643 BROOKS CT BAKE~SFIELD,CA,93308
OFFICE(661)392-8687 & FAX (661)392-0621
ACURITE TM PIPELINE TESTER
Precision Product Line Test
TEST RESULTS
Test Date:lO/ll/04
BILLING:MEMORIAL HOSPITAL
420 34TH ST.
BAKERSFIELD, CA
SITE:MEMORIAL HOSPITAL
420 34TH ST.
BAKERSFTELD,CA
PRODUCT PRODUCT lv.ŒCHANICAL MONITOR
PRODUCTS LINE TEST LEAK DETECTOR LEAK DETECTOR
DIESEL -,ODD-PASS N\A ANNULAR & SUMP
DIESEL VISUAL FAIL DO TO STRIPPED FI BERGLAS S 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 pénalty 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.
::t~;Ü
C¿;~~-1072
.(:: -" :, ~
RICH ENVIRONMENTAL
5643 BROOKS CT BAKERSFIELD,CA.93308
OFFICE(661)392-8687 & FAX (661)392-0621
ACURITE TM PIPELINE TESTER
WORK SHEET
DATE: /ð-IJ-()"I
W/O#:
Facili ty Name: n'f;t'7(?tt/-fL.
fÍ()jf tr" L
Facili ty Address:!::IM .J'1Tp.. ,.fï
ß'+A::~;IÇL 0 J ~
Product Line Type (Pressure J Suction I Gravity): ~c.)(.Ì'lð'1.,.)
Pump Hanufacturer: .JJ I tA.
Isolation Mechanism: PotJT u.f'.."'¡-
PRODUCT
START TIME
/READING
OO:OO/GPH
II :CJð.
TEST
PRESSURE
(PSI)
VOLUME
RATE
(GPH)
~~
RESULT
PASS/
FÄÍL
-.O-S
_~L.
I certify ~hat Lh2 above line tes~s were conducted according to
~he equipment manufacturer's procedures. The results as listed are to
my knm.¡.ledge true and correct.
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 psi which
ever is greater.
St.ate License: # 90-lo"'~
MFG. CERTIFICATION: # 60a.LT
1J'~u.tL ~vE
Fl'tìJ~ J-U
~ i,OVIV-Q "FA'I LJJ(LE- OcJ/E.
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MONITORING SYSTEM CERTIFICATION
For V$e By All Jurisdic1ions Wj¡hin ¡he State of California
_-lIlfhoriry Cired.· Chaprer 6.7, Healrhand Safery Code; Chqpter 16, Division 3, Tide 23, C'71ijòrnia Code ofReguh¡¡ions
This 1'o1'1n nms, be used {Q document testing and servicing of monitoring equipment, A separate certification or report must be prepared
for d·i..:Ìì mOflÏtoriflg SVSlelìì comrol panel by; the technician who performs the work. A copy of this form must be provided to the tank
SYS¡;ëlll owner/operator. The owner/operator must submit a copy ,of this form to the local agency regulating UST systems wirhin 30
lid)::; ()f lest darè.
A. Gt:.fiëcallnformation
Facility Namè: r1þfY)d e", 4-'- 1Je;~P 1'r'4-'L
SiTè _"'-ddress:.!1 >{) :> 4 ru-- ~T
Facility Comac¡ Pèrson: (2OG'1 pf .
IVbkè,lVlodd of Monitoring System: ðwf:4J5 - (ßj fl4JJ41¡ .
R. Inve.ntory of Equipment Teste4lCerrified
CJ¡",I: [1", ;¡ ) )J"¡) dare boxes to indicare s eciJic c¡ lii mcllt ius )ecred/seJ"\'iced:
'L¡¡¡j. i.D: --Pb L -~
o In-La1k Güuging Probe. Madej:
~ ,-":i1111ILu: Spacè,~r Vau!~ Sensor. Model: ~J ((JOAIJtfJ~
tJ Plp1llg Sump! lrellch sensor(s). Model:
o FilJ Sump Sensor(s), Mode!:
o )\kdHu1Íca! Line Leak Defecror. Model:
o Ekt.·u\\ ¡jc Line Leak De¡ecrof. Model:
o Li.nk Over1Ï1J / High-Level Sensor. Model: _
o ()fhè~: (S ecit\' e ui mel1t tv e and model in Sþcfion E on Paoe 2 ,
'[¡wli. ID:
o In-LUll;: Gauging Probe. Model:
I 0 ,-\..1ìJlubr Spacè or Vall!¡ Sensor. Model:
I 0 Piping Sump 1 Trench Sènsor(s). Modèl:
I 0 FiJl Sump Sensor(s). Model:
o )\·kckU1ical Line Leak: De¡ector. Mode!:
o EkWùJlic Line Leak Derecl'Or. Model:
II 0 'LU1k OVèffill / High-Level Sensor. Madej: .
II¡to U.' [J~èrlsfJè"iI\ è. ui l11ènt t)' e and model in S¢crion E on Pa'e 2 .
I Dispenser ID: ~ '
:¡ 0 Di~ptusèf COl1lainment Sel1sor(s). Model: '
¡III 0 ::>hdr Va!vè(s). '
t~_Dj~£.cllSèr Comainmem Floar(s) and Chain(s)..
!I Dispenser 1D:
! 0 Di:;pellsef Containment SeI150r(s). Model:
[I 0 She'LI'VaJvè(S).
11_ q Qi.-;f'tl!Sèr Containment FJom(s) and Chain(s).
Dispenser ID: .
il' ~ l?ispèJl~èr COntuiJ1l11èm SeJ1sor(s). Modèl:
¡ U ::)hc,U' 'v d.lve(s).
LOJ':)~spènsèr .c0n¡¡¡inmenr FJoat s) and Chain(s).
'lfrÜè ÚII.:iJÜy comains more tanks or dispensers, ~opy this 1'01111.
City: ß-ð-I{,$¡'SFIF(",D
Bldg. No.:
Zip: '3Jå J
Contact Phone No.: ( )
15" cr - J. Date of TestinglServ icing: JtL¡ -'1-/ ~
....
TanJ{ ID: TJS L.--1ÆAq:i
o In- Tank Gauging Probe. Model:
jlJ Annular Space or Vault Sènsor. Model:o-.J£UJ ~(/þi:ItJ..LNfi)_.
o Piping Sump / Trench Sensor(s). Model:
o Fill Sump Sensor(s). Model:
o Mechanical Line Leak Detecror. Model:
o Electronic Line Leak. Detector. Model:
o Tank Overfill / High-Level Sensor. Model:
o Orher (s eci', e ui mem t e and model in Section E on Pac :2). _
Tank ID:
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). .lvlodel:
o Mechanical Line Leak Detector. Model:
o Elecfronic Line Leak DetecIOr. Model:
o Tank Overíìll / High-Level Sensor. Model:
o Other (5 eci e ui ment ' e and model in Section E on Pa -e 2).
Dispenser ID:
o Dispenser Conrainment Sensor(s). Model:
o Shear Valve(s).
o Dis enser Containmènt FJoat(s) and Chain(s).
Dispenser ID:
o Dispellser Conrainmellt Sellsor(s), Model:
o Shear Valve(s).
o Dis enser Containment Float s) and Chain(s).
Dispenser ill:
o Dispenser Containment Sensor(s). Model:
o Shear Valve(s).
o Dis enSèf Containment Float s and Chain(s).
Include information for every tank and dispenser at the íàcitiry.
C. Certiileation -I certify that tbe equiptflent identitied in this document was inspected/serviced in accordance with tbe manufacturers'
guiddini:s. Attached to this Cer(iticatio~ is informacion (e,g. manufacturers' checklists) necessary to verity that this informatioo is
':OITe.:r àud à Plot Plan showiog the layou~ of morlÌtoring equipment. For any equipment capable of generating such reports, I have also
_, arr¡¡¡;h¡;d a copy o~' rhe report; (check /11/ Ih~¡ /lppM: 0 system. ~et-up O~lan~epO 't
lècl1mCl:ill Namè (pnm): "y4'U 1"14St1V SIgnature: _~~
c..'c:nirìcmionNo.: tI~(;,OS-" /J7-'7 License, No,: 61/D40- #~'p9850
TesÜngCùmpanyName: RICH ENVIRONMENTAL Phone No.:(661 ) 392-8687
Silcr\ddrt5S: t/Jð JtJTIf iT 84J(.$UPI/./.,rQ¡ c--1- 'JJP/ Date of TestinglServicing: ;dIll I_~
1VloJÌiwring Systtm Cerri1ïcation
Page 1 of3
03/01
t , . ..
D. i{.èSliÌtsof Testing/Servicing
..
SoÙ\\ Jfè V.:r:3ion Installed:
. CÙil1pkr¡; dìèfollowinü Chécldist:
l1t Y èS 0 No" Is me audible alarm 0 . erarional?
~ \~ U No" Is ù1e visual alarm 0 erational?
YeS 0 No* Were all sensors visuall ins ected, functionall tested, and confinned 0 erational?
j(ì \\:s 0 No" Were all sensors instaped at lowest point of secondary contairunent and positioned so that other equipment will
not imertère wirh their ro )er 0 eration?
o No'" If alarms are relayed to a remote .monitoring starion, is all communications equipment (e.g. modem)
. N/A operational?
For pressurized piping systems, does the tu!bine automatically shut down if the piping secondary containJ1li:nr
moniroring system detects a leak, tàils to operate, or is electrically discormected? If yes: which sensors inil'iatè
posirive shut-down? (Check all that apply) . a Sump/Trench Sensors; a Dispenser ContailUnenc Sensors.
Did 'ou confirm ositive shm-down due to leaks and sensor failure/disconnection? 0 Yes; 0 No.
No" for rank systems th~t utilize the monitoring system as the primary tank overfill warning device (i.e. no
NiA mechanical overfill pI:evention valve is installed), is the overfill warning alarm visible and audible at the rank
fill oim(s) and 0 era¡íno )[0 erly? [fso, at what ercent of tan!< ca aci does the ala.rm tfiü er?"O 'Yo
Was any monitoring equipment replaced? If yes, identifY specific sensors, probes, or other equipment replaceJ
and Jist the manufacturer name and model íQr all re lacement arts in Section E, below.
Was liquid found insiete any secondary cont~inment systems designed as dry systems? (Check all ¡hat apply) 0
Producr; 0 Water. l~ es, describe causes in Section E, below,
)SI \' èS 0 No" Was monitorin s stem set-u reviewed to ensure ro er settinas? Attach set u
y çs 0 No* Is all monitorina e ui mem 0 erational er ma.nufacturer's s ecificatiol1s?
" In Si.'ccion E below, describe how and when these deficiencies were or will be corrected,
CJ \ c:s
U \' eS
I I
,I
il ~ 'è> I g
II [j y,,' )ð No
I :.J YeS" ~ No
(icable
E. Cü.l.Hmencs:
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Page 2 of 3
03/01
- .¡
F. lü-'Lull-: Gauging / SIR Equipment:
fit Check this box. if tank gaLLging is used only for inventory control.
1:1 Check this box if no tank gauging or SIR equipment is instalkd.
';
This sèèrion l1.1.ust be completed if in-tank gauging equipment is used to perform leak detection monitoring.
CUú'1'.!'\t {li¡; fùllowifio cnecKlist"
, J ç
0 \1"';$ 0 No'" Has all input wiring been inspected for proper entry and termination, including testing for ground faults?
-"
0 ').'çs U No" Were all rank gauging probes visually inspected for damage and residue buildup?
0 ·Y.:s 0 No* Was accuracy of system product level readings tesœd?
.
DYes \ 0 No" Was accuracy of system water lewl readings tested?
f---~
o Yes 0 No" Were all probes reinstalled properly?
U Yes 0 No* Were a1J items 011 the equipl11em manufacturer's maintenance checklist completed?
" 111 llle .sè~tion H, below, describe how aud when these deficiencies were or will be corrected,
G. Line Le¡)1\. Detectors (LLD):
,94' Check this box if LLDs are not instaJled.
l.Ollil) tIc { Ie o OWIß¡;: c ec :
o Y'èS 0 No* For equipment start-up or annual equipment certification, was a leak simulated to verify LLD performance?
0 N/A (Check all that apply) Simulated leak rate: [:J 3 g.p.h.; 0 0.1 g.p.h; 00.2 g.p.h.
0 Yc's 0 No* Were all LLDs confirmed operational and accurate within regulatory requirements?
0 'YeS 0 No'" Was me testing apparatus properly calibrated?
U Yè:$ 0 No'" For mechanical LLDs, does the LLD restrict product flow if it detects a leak?
0 NlA
0 YeS 0 No'" For electronic LLDs, does the turbine automatically shut off if the LLD detects a leak?
0 NiA
0 YèS o No* For elecn"onie LLDs, does the turbine automatically shut off if any portion of the monitoring system is disabled
I o N/A or disconnected?
0 YèS 0 No'" F or electronic LLDs, does the turbine automatically shut off if any p0l1ion of the monitoring system malfunctions
0 N/A or tàils a rest?
0 \'ë;S 0 No* For electronic LLDs, have all accessible wiringcoIU1ections been visuaJly inspected?
0 N/A
U Yes [0 No'" Were all items on the equipmenr manufactur~r's maintenance checldist completed?
t f 11 . a h klist
;,. iü (he Section H, below, describe how and when these deticiencies were or will be corrected,
1-1 Comments:
-- ~,'------'-'--'
---_..~---
------
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Page 3 of3
03/01
. ~ .~. ..
r\
! l\'iûil.ilûring System Ce¡·tificatioß
Sir" .-\.ddn::ss: n'l;'O
UST lVlonitoring Site Plan
;;'lTH~ ~F/Þ"'£3 C4- 9J»/
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If you already have a diagram that shows all required information, you may include it, rather than this page, Witll your
IvlonÍloring System Certiíìcatioll, On your site plan, show the general layout of tanks and piping. Clearly identify
IO(:Jrions of The following equipment, if installed: mon.itQrin.g system control panels; sensors monitoring tank annular
spaCeS, sumps, dispenser pans, spill containers, or other secondary containment areas; mechanical or electronic line leak
clèTè(:[OrS; and Ìl1-[ank liquid level probes (if lIsed for leak detection). In the space provided, note the date this Site Plan
\\<1'; prep:1fed.
. . . .
. . . .
~~«~J-:
Da[emapwasdrawn:~ II /&17
Instructions
Page ~Of~
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-COpy RSQUESTSÐ P~EAS!
FAXC~61)3g2-0621
CrrY OF BAKERSFŒLD
OFFICE OF ENVIRONMENTAL SERVICES
·'100 "'f'J2U.Xmn ~. -~R5~ÆL}) 1 c.A
~ (tø.(o O.g.s~..- ó)\ ì.t
APPLICA TIO.N TO PERFORM
FUEL MONITORI;NG CERTIFICATION
FACD...lTY ml'U'O(,,)~14( .J:Jo5P IT"J'\ L
ADDRESS J..f ()..Q . ~ ~ ~ .'3r-. '
OPEMTORS NAME Ct&)
. OWNERS NAME ~ '¡juJ
NAMB OF MONrI'OR MANUPACTUlU3R.
DOES PACII..lIY HA VB DISPBNS11R PANS?
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~B\<'~~V\ Fl Pi, C~
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TANK'
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VOLUMB
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CON'ŒNTS . .
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NAMaOF'IBSTINOCOMPANY . RIÇH ~l'lVIRO~D.rBNTAL i : ..
CON1:RAcro~ UCBNSB if ~O-l 072
NAME lit PHONE NUMBER. OP CONTACT PERSON JAMES RIca ( 661 }3 9 2-.' 87
DATU TJMB TIJSI' IS TO BE cœmucn¡p ~... - ~:ro~,.,Æ¡' r ·
. .i/(ÆavrO 1/;;'Î~i~, nt~ ,j ·
A.PP&OVBl> BY DÅTB.. SIGNATURE OF APPLICANT' :
'-
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S,\\i R.CI.:!, hnuary 2002
Page -L of ~_u
"
Secondary Containm~Dt Testing Report Form
This jÒrm is ¡mended for use by contractors performing periodic testing of UST se.comiCU')J containment ß)J.rteTnS. US(l thil
iipp1'L)pria~e pages oj:thisj'o,:m to report l'esultsfor.olJ components tested. The completed form, written test procedures, and
prj!1wuts from lests (if applzc.able), should be proVlded to thefacility owner/operator for submi!taJ to the loc.a1 ref;Ulafory agenc.y.
1. FACILITY IN.FORMATION
I[ FaciJny Name; ~,
\1~f~~D~)' AddH:SS: 4JØ ;J 0/7# . (T t!-
It ¡:aci li.y Contact:
¡~--_.__.
IL[!~~~OCal Agency Was Notified of Testing : ,e¿J(,$'t .
,l_N.;;l~::::'~ of Local Agency Inspector (ifpresent during testing): ~d~
...
r_~~~;ìp~~·;1~~m~: R.I~~ ENVIRON~ŒN'l'AL ., ..
f:r'dUlician Conducting Test: ~l"-1V ~;....J ,
i.yredel1!ials: ¡gCSLB Licensed Contractor o SWRCB Licensed Tank Tester
Liœnse Type. C611 D40 ··1 L¡c~t.\ Number: 809850
F·~n......"~~...,.'''~~.~....,..... 'l\~"'.r
", ,to " ",.'~ ,L, ..".' ".
Ma'øfv'þIrer Trainip.g
I Manutàcturer C011.1nonent( s) Date Traming EXDÍres
-_.--- 8/04
INCON INCON ~S-STS
--_."--,--- , .
--
------
--." -
2. TESTING CONTRACTOR INFORMATION'
\ - Component Pass Fail Not Repairs Component Pass Fail' Not Repairs
Tested Made Tested Made
JI fJ 0 'D 0 0 Ò 0
I QS.~ FI t..~ 11 oI)C j 0 0 '0 [] 0 0 0
1--. 0 0 0 '0 0 0 0 []
r- 0 0 0 0 0 0 0 [I
0 0 0 "',;.'"" 0 0 0 .0
0
[===-=~. 0 0 0 0 0 0 0 0
I [J 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 [J 0
0 0 0 0
- "- --'. -
3. SUMMARYOFTESTRESULTS
if hydrostatic testing was per~Q.m1ed, describe what was done with the water after completion of tests:
-'----'
RECYCLE AND REUSED
-.----------
CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THlS TESTING
T<} t/xe hesÌ of my knowledge, the acts stated in this doqunrlµlt aTe accurate and in full compüance with leg,,1 Ttlqui,.e~ts
/7
Date: Jd-IJrl?"/
T èchnician's Signature:
FaciÙty is Not E~luipped With. Spill/Overfill Containment Boxes 0
SpiJJ/Overf¡ll_~~:)J1tainment Boxes are Present, bcrt were Not Tested 0
H__"-;:='" __ ___ _ _
Ti.':SI Method Developed By: 0 Spill Bucket Mai1ufaCtUJ:er
o Other (Specify)
o Pressure
o Other (Specify)
INCON TS-STS
~
.... -
.
'1
S Vv'RCB, January 2002
__ _._._.__________0
TèS[ l\llëthod USi.';d:
l-1'~:~~-E~I~.iE~n~nt Used:
[:.~::,."c:~;''r·"''1~·.:~~ß!C:?:
~~~: ~~:r'
I WaÍI rime bètween applying
I pr¢ssllre/vacuurn/water and
! S(;;lrÜll~ œst:
\- -~- --.-""-
l'esr Starr Time:
lniLiaJ Reading (R¡):
Test End Time:
Final Reading (R!,):
Test Duration:
I (~hangè in Reading (R¡:-R¡):
P~ss¡Fail Threshold or
Criteria:
T.es~ Result
Page --.d-of __~_.
9; SPILL/OVERFILL CONTAINMENT BOXES
ñö. Industry Standard
o Professional Engineer
o Vacuum
S Hych"ostatic
'pmentResolution: . oooin.
Spill Box #
Spül ox #
J() ~ Vt.J
.00d,.v
}4 Pass
.O~''Ÿ
o Fail
o Fail
,OOJ.. -u
o Fail
o Pass
OFaü
OPus
J; onunen ts - (include information on repairs made prior to testing, and recommended follow-up for failed tests)
.--.---.-.--.-'
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10/18/2004 10:21
6613920621
PAGE 02/09
MONITQRING SYSTEM CERTIFICATION
POI' Use By All J1J¡-isdiclÎons Within the Slate ofCaliforn;o
,.·il¡¡bOl'flY CJ¡ed: Ch,lpter ó.7, Heallhand Safety Code; ChQPter 16., D;yir!Oh 3. Title 23. California Code of Reg/llmions
Tllis fül'lu must be u~ed ro document testing Uld set'V'icing ofmonitorìng equipment. A S~Ðarutc çertification Or report muSt be crr:pàred
for ~'I.;;h moqitoring systen, control panel by: the technician who performs the work:. A copy oftbls form mun be provlded to the tlillk
~y~n:llI O\\'~1erlopc:nttor. The ownerloperator roust submit a copy of this for.rn to the local agency regulating UST systems within 30
lhk>.~ l)f ¡~~t dl\lc.
A. Gt:J1eral }n1'armation
.r·lidlhyN:1l11ë: YI.~I!44-L-_ ~Pl~
Sire Address: ...,)oð , '" TItt -:¡tL-
F.,ç ¡.liI) Cantllc, Pel'son: ~1 ~ .
l'vu'I!,c:iModd o{Monltoring System: ~..uS - GO..W.J.&lfj
:ß. Jnvt!o.tor)' of Equipment Tested/Certified
('¡lcd, rh" ;1 ~ Jro JrÍlLle bQ~~s ro iDdíCI1Jt S ~1I1~ e ùi m~IIJ In~ e~ted/s<,r...ic<,d:
BJdg, No,:
___ City: ß"'It.¥~SF,F¿¡¿,_~ Zip: ~;Jð J
Contact Phone No.: ( )
Fa- - J.. Date of Testing/Servicing: 1(}_-, .lL-Jt?~
Tal~k W: _-Rb L Tank ID: ~.J-..
o !iI-Tank Gllu~i[\g Probe. Modcl: [J In-Tank Gauging ?fIJl)e, Model:
~ Anilular SPdJ:¿ Or Vauh ScnSOr. Model: ~ 'oUlflfiJ jØ. AnnulàJ' Spaœ or Vault Sensor, Model: ~~~~~.
tJ P¡ping Sump l Tl'lJDCh Sensor(s}. Model: ~ .. 0 Piping Sump I Trench Sensor(s). Model:
Q Fill Sump Scn~or(s}. Model: Q Fill Sump Sen.'IOr(s}. J'vU;¡dcl: v___~.:::
o 1'...j,;dHl1li~¡ 1 .l.ino: 1..Gàk Detector, Mod~l: a Mechanical Line Leak Dl!:tcctor, Model:
o rJ,:c1J'(\uic Li )~ L.:ilk DéICC[Or. Model: 0 Elecuonic Line Leak Detector. ModeJ:
o r~lI1k O\'~J'll J / Hlgh·Level $emmc. Model: _. a TáDk Overfill I J:oIlgh~Level Sensor. Model:
c:J Oth~r (~JcL'i" . uj n\ent I ' e and model in Section E on l'a'(I 2 , a Oilier s ci . c ui mem t e find mDdc:1 in Section .E on Pa 'c 2).
'l\wk lD: TAnk ill:
Û In- 1'11,111;. Ga'J~ging .Probe-, Model: _. [J Ill- Tank Glluging Probc. Model:
o AUIIUhll' Sp8C~ úr VaLllt Sensor, Modcj; a Annular Space or Vault Sensor. Model:
o .I'ipin!i, SU( )~, I TI'.::l1t'h Sèl1Sl>r(S}. Model: 0 Piping SU!11P I TrcocJ'¡ Sensor(s). Model:
Q f.iIJ Sump SeI1Sl)I'(~}. Mudel: a Fill SImIP $cmsor(s). Model;
Q !\'l~.;hilnical Lin..: teak Del~CtOt, Model; _ 0 Mcchaaicall.¡nc Leak DeIccror, Model:
(J ¡-:I.:mL>llic LiM L~Bk Dctcctor. Model: ~_____.~ C Electronic Litle Leak Detector. Model:
CJ 1'; k OV<!J'lIJJ I High-Level S..:nsor, Model: __ 0 Tl1nk Oveltìl1/ High-Level Sensor, Model:
CJ Urb~ ' t;¡ c!1:jr'y ~ III l11enr t e and modl!J in Section E on Pa e? . CJ Other s eci c ul mc:nt 'e aru:I model in Section E: on Pa c 2),
DìS¡¡¡:Dser ID: :Díspenser lD:
o Dl:öp;:nscr COlua.iIU11cnr Seosor(s). Model: Q Di!lpcnser Containment Sensor(s). Mode!;
o Sh.:al' Vtlh'e{~), 0 Shear Vnlvets),
CJ Dis .1~ )~ð ' Cont¡ljnmenr Fh)~1 3 and Chain s . 0 .Dis cnsCI Containment .Float s and Chain s .
.Dib¡lCIlSIH'ill: DIspenser ID; .
o L)ispç )~~ ' Cunlaillmo;:nt Sen~aI(s), Model; 0 Dispenser Containment Sensor(s}, Model:
o Sh~u¡, V~I\lCl.s). 0 Shear Valve(s),
o Di:> èn~~I' Conl;ii!lm~m Host $) and Chain s . CJ Dís nser Con.tainmenr Float $ IU1d Chain 5 ,
Dis¡>el1~eT .ll): _ ," a Dispenser ID:
1:1 l)i..¡¡><!n>~l' COlltl1i1uncnr S~"sor(s). Mod"l: __ 0 Dj£pellSer ContaínmenJ Sensor(s). Model:
o ~hcar Val\'t1ls). 0 Shcar Valve(s).
CJDi:; 1c.'nSc!T CÙDI'II.inml!nI Flollr s o.nd Chain ~). a Dis enser Containment 'FJOflt 5 and Chain !I .
-1fth.: tilCility conrains more tanks Or disp~nser!l, ~opy tbis fann. Include information for every tank nnd dispenser at the fACility.
C. Certit1cation - 1 c.-lily tb.øt the e'lllipOlent identified in tbis dòtllòlent was inspected/serviced In accordance witb the manufacturers'
gllideline~_ Attmlhed to tbls Cllnlticatil)Q is information (e.g, mAßufactureñ' checklists) necessary to verily that this information is
a:( rr~l:~ .and 1:1 Plot Plan !lhowing the layuü~ ot' mOllí(()ting equÎpmGnt. For Dny eql"pme.nt capable or generating SlIeh reports, I havl> DI~u
"œ,b,' , ,.or ., lb. ......1; (d"'" ai, thiu nppl..' 0 .>"'''' "'-'P ~~."
1'ccluúciliIl Nam~ (priot): -1!.Y.-4'V YI.:!6J,,;U __ Si¡nature: ,
Ct!T[iíkuioD No.: ()tJfß.. (I~.. J) "].., License, No.: 61/D40- # ~.pge50
IçstiLJ~('¡)mpZl.ll>'Name: RICH ENVIRONMENTAL PhoneNo,:(~61 )~-B667
Site AddJ·~.'Ss: !LJ:()_~ <IT /J4-xÞgp /$1, () r~ ,.v~L Datc atTesting/Servicing; -L!!!!.LJ ~
....----.
Page] ofJ
OJ10 1
!\1ollicorillg Systc!m Certification
.
.
10/18/2004 10:21
6613920621
PAGE 03/09
Süfl\\ jj-': Ver~i0J11ns(l\lled:
0. R~~rlJhs of rfesting/Servi~ing
Cù!il 'ICOI'<:, dl~ (Ollowioa chec djst:
~ \'èì 0 No"" Is the audible all!Cm 0 eratioaal?
fi!!I y~.,¡ 0 No~ Is the "isual alarm 0 . rariol\o!'?
Ÿ~2 UNo· Wel'e all sensors vÍ5uaJJ i )s ected, functiona1l teste al1d confirmed 0 rational?
jd Y.;:s 0 N¡)* Were all sensors instaUed at lowest point of secondary containment and positioned so that ocher equipment wUI
not interfere with their 1'0 ).::t' 0 eration?
If allU'ms are relayed co II remote .monitoring stBtion, is aU colll.l1Junications equip1T~cnt (e.8- modem)
operarional?
Fat· pl'essurized piping systems, does the t~lrbine lluton111tically shut dowu it the piping secondaJ)' .::ontaÍl\l\'lC!\(
monlr\)rìng system derects 0 leak, fuils ta operate, or is eJeçtrically disconnected? If yes: which se.nsol'~ inj[it1t~
positi...e shut-down? (Check an that ðppl}') 0 Sump/Trench Sensors; 0 Dispenser Containment Se.1S0rs.
Did ou conûm1 sil.Îve 9hur~down dll9 to leaks and sensor failure/disconnection? 0 Yes· 0 No.
D Nö'" FQr rank systems that utilize the monitoring system. 8S the primary tank overfill wamínz. device (i.e. nO
o N/A mech!iJ1i~al overfill prcvention vI11ve is installed), is the overfUl warning alarm vLsible and ~llldible at the mnk
fill oint(s} ß1\d 0 eratin )ro erl 7 [f so. at what ercent of tank en ací does the nlartn tri . er? I .'o
Was any monitoring equipooont replaced? If yes, identify s~cit1c :¡ensoIS, probos, or other equipment rl:pl!1ced
an.d lisc the D1J'JJ1L1factuter nan1¢ and model tòr aIJ re lacemenc am in Section E, below,
Was liquid found inside any s~condary conrainmet1l: systems destgned as dry sYStems? (Check all that appl)l) 0
Product' Q Water. I( es, describe ~a1.lSes in Section E. below.
B '{c:) 0 No'" Was mOl\itorin 9 stem sec-LI reviewed co ensure ro settjn s7 Attach set u
'y'çs a No* Is allmonitoritJ e \JI 111elll 0 eratiolUlI er manufacturer's s cificatiol1s?
'" in S¡:çtioll I: below, describe how and wben tbese d~fit:ieneies were or will be corrected,
. 0 \'I.:S
o NIJ'"
,N/A
a No·
Ji!P N/A
a \'.;s
~5 y,"
LI Y~:i~
I No
Q Yè!ò*
õt No
.f.. CO.l.Uments:
l!cable
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...--...... .'----
_. ....-.- ..--..--'
..... -.-... ,"---'---
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... -"-"-"--
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Pille :2 of.1
03/01
i
~
10/18/2004 10:21
6613920621
PAGE 04/09
Jf, lo-T~nk Gnugiug I SIR Equipment:
1! Check thi¡ box. if tank saugir'i is Llllod only for inventol)' contl'OJ.
o Cb4)ck this box. if no tank ga~giT\i or SIR eql1ipJD@nt is Ìl1S~111ed,
Thi:!; scc£Ïo.n must be completed if in-tank galJging equipment is used to perfoml1eak detection monitoring.
COlli r:.l4!t~ t I~ öllow nil: cb.ecklbt:
o y~~ o N¡J* Ho.s aU input wiring been iMp(),m:d for propcl' entry and termination, ï.ocluding testing for ground mults'? ...
~..'~'-
U \'.;,; Q No'" Were all tank gauging probes visually inspected for damage and residue buildup?
O\'Ói o Nol!< Was accuracy of system product level rèadin~ tested?
-=- ~"'~
Q 1;;$ UNo· Was accuracy of $Y$tem watèr levcl readings tested?
a y~,.;¡ Q No" Were all probes reinstalled properly?
r-=---
o Yr;$ a No· Were. all Items on the oquipm~n[ IruInufacNreT':¡; )~¡'uel')ance checklist cornplet.ed'1
'====' ..-- -
I r
,.. 111 m~ s~ction J;;I., belQw, describe h.ow and when these deficiencies were or will be corrected.
G. Line Leuk Detectors (LLD):
j1d' Check this box ifLLDs are not iostaUed.
CU(U1)J~rl! tbe: followine: checklist:
Q y~s Q No" FOl' equipment start·up 01' tIllllual equipment certification, was a leak simulated to verify LLD perforn'l8néc?
o N/A (Check all that appl)l) Simulated leak rate; Q 3 g.p.h.; a 0.1 l;.p,h; Q 0,2 :,p,h,
a Y~'S CJ No· Were .all LLDs confirmed operationa.! and accurate withìn regulatory requirements?
o \/~: a No· Was we testing apparar.us properly calibrated?
o y~:) o No" For mechanical LLDs, does tlle 1.l.D restrict product flow jf it detects a leak?
a N/A
-=-' t:J No* For eJectronic LLDs, does the turblne a.utomatically shut off ¡fthe LLD detects a leak?
o y~s
10 N/A
o '\{~s o No" For electronic LLDs, does thr) turbine automatically shut off if any portion of the monitoring system is disabled
o N/A 01' r; isconne~ted?
0 Yes (J No· For electronic u..os, does th~ tLlrbine automatically shut off if any portion ofth.e monìtoring system maltùncriol1s
D N/A 01' fails a test?
0 Yes o Nl~'" For elecrronic LLDs, have aU accessible wiring con.nections been visuaJ\y inspected?
o NlA
o "Ùs o No" Were all items on the equipment manufacturer's maintenance checkli$t completed?
w In clu: Section H. be ow~ desc:ribe how and when these det1deneles were or will be c:orrel:ted.
H., C()(lun~nts:
-.. --_.~_...'."
-.-,.."..-
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Page 3 ofJ
03101
..
~.
1B/18/2BB4 1B:21
661392B621
PAGE B5/B9
Mtmitol"ing System Cllrtìth:ation
UST Monitoring Site Plan
Si¡';A,jdl"ess:___VJ.t)~_-2'ITH .IT ~/¡þ-¿4 c.,+- 9J~/
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Date map was drawn: -A:2! II / d
Instructions
If }~}(.l tlJf~¡1dy have a diagram that SbOW5 all required informacion, you may include it, rather than this page. with YOLll'
M.ùniLo!'ÏJ3g System Certification. 01,\ yom site plan, show tIle general Iltyout of tanks and piping. Clearly identify
lo~;trions of th~ following equipment, if installed: monitoring system control panels; senSOrS monitoring tank ~ni\ula["
sp~l\:es. sump¡¡, dispenser pans, spill cOl1tainers, 01' other secondary containment areas; mechanical. or electronic hM leak
der~'.;tol·~; and in-mnk Hquid 1eyel probes (it uged for leak detection), In the lòpace provided, note the date thi.$ SitB PLal\
\....IS prepaJ"r:!d.
Pag,è ~ Of!i.-.
O5lUO
~ -.
! .~~, """,.
,.-
18/18/2884 18:21
6613928621
PAGE 87/89
SWRCB. laJ.1ltJU'Y 2002
h&c: -L of~_
Secondary Containment Testing Report Form
ThS$ flJrrn js Imllrll.fød fa, 118' bjJ fJO"t1'Q&.tOl" pørf01'mlng pu1odlt! ("tin¡¡ oj US'/' &lIr::ondlU')J Cr»1ta1nm11nt I,V.ttanll, Usa thl
appTiJpriatf p ~:r.1!}J of Jhis {orm to report re.ml/~ 1"1' all Q(;Im.pClnants ruted. The cømpÙltedfo/'tn, 'Written tut pt'o~u. tmd
prìntrJIII3 from rests (if QPplJCt2ble). .thou/Ii be próV~ to t/f8~tJity ~nørIDp"r(l1tJl' for s'll.bm~ to the local ,.eplato", agency.
1. FACn.t1'Y 1NBORMAnON
~
",
2. TESTING CONTRACTOR.1NFORMÂ.T1:OX·
S~1!1'pany 'Na.me: IUCa ENVIRONMENTAL .
l'~~ll\ician Conductiñg 'Test: ~~A-..v ~~
C reL1eutiAls: IX CSLB Licensed Contractor J SW1lCB Licensed tank Te~
-- I Lic~~ NU1nber.
License Type, C611D40 809850
~N'.-VUl"er TrainiU Date- , ,
Manufacturer COlUDonmttls' ëxDÍl-es
-~ INdON TS-STS 8/04
¡NCON
------
f-..--
Cornponent Pass 'an Net ~ Coœpo..øt }tøs J.il' Not ReplÛn
Tested i 1'Mted. Made
f----- Ò
.ºí~~...Ð u... A ØI~ II 0 0 0 0 0 o.
~b PI I..l J1~ ~ 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 Q ,0
__6____- 0 0 0 0
0 0 0 0
0 0 0 0 0 0 0 0
0 0 0 0 Q D 0 0
.~.. 0 r:¡ 0
0 0 0 0 0
--. 0 0 0 D
0 0 0 0
.~ 0 0 IJ 0
0 0 0 0
--- 0 Q 0 '0 0
0 0 0
3. SUMMARY OF TEST RESULTS
tf bydt'o1tatic testing was per~ d.eactibe what was done with the wat.e.t after complætioD of tests:
__ f'
J;<.ECYCLE AND R~USED..
CIi:R'J:'lFlCATlON OJ' TECHNICIAN BUPONSIBLE FOR CONDUC'I'lNG TØ1S TJlS'1'1liG
1~ t"~ bt!ll of"~ J knoJPladgfr, tñe Ød.t ,'atld ÎII ibis dIH!JlmBlrt 4tl! IlCCUf((fe tIlJd lnÞ.U compl/lznl;t:",1IIt Ieg.' f"IIfpI~
/l
Pate:./d-¡Y'Y
T ~chl1jcian's S ignaturc;
~
;¡.
10/18/2004 10:21
6613920621
PAGE 08/09
~ 'Jo..'RCB, Jaouary 2002.
P.~~_.
9. S ·IL.L/OV CONTAINMENT :SOXES
F¡¡<.:iln ~ Not 1.li ed Wid1 S nt/Overfill Contamøumt Sexes Q
SpllUOve1i.íU CO lWtlm.ent Boxes are Present, but were Not Tested Q
T~:>t MethoC1 Developed By: a Spill Bucke.t Møimfa.œufer
Q Other (Spec¡ß.oJ
o Pressure
o Other (8pt:!c¡)Ý.
'l'S-STS
ø Indusl:r'y Standarc\
Q Pro1!essionaJ &,aincu
-....-.---'
'\'t:\\t M~thod Used:
tJVacuuro
II Hy<Itostatjc
-.------
Box#:
5
x#
i)u~\<.èt Ciá.t\'\~f:¡:r:
~uck.et ùtpth:
W:1.ítti~tween applying
prçs$I.I..reJva.;uu.m/waìer and
~.~~\l1~ .tèst:
fast Sti!rt Time:
lnil:.ÌùJ R.eadi 111(: (Rt);
Test End Time:
Final Readit\~ (R¡:):
T~st Duration:
Cht\11gt1 in Reading (R...-R,ù;
?;sslF ail Threshold or
g-~~
Test ResuJt:
.! 0. """ V"
.~.v .~."" . OOø.~ .ajJ.. "Ù
Jl Pass 0 FAiJ .8' Pass 0 FaU
[J Pus Q Fail
OPus
[J r.n
Ü:)lnment$ - (includz i!formmlon on røpaiI"J made pl'1Q/' Ie turlng. IZI'I4 1'8éomml11dødfol/OW-rJ{J fo,. fQl1ød tefta)
-..----
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......---
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-----
-....-- ..
09/27/2004 14:36 6613920621
PAGE 01/01
*COpy REQUESTED PLEASE
FAX(1;)61)392-0621
CITY OF BAKERSFIELD
OFFICE OF ENVIRONMENTAL SERVICES
·'ŸOO 712l1.Xmn ~..-~¥<~rFtE.Q),U¡
mX ((O.l.o\)-8'Só(..-éHì~ .
APPLICATION TO PERFORM
FUEL MONITORING CERTIFICATION
FACILITY (ý) fC.%V1()r<I.Q( i Hosp I-~ l
ADDRESS yacJ. '3 ,:/71+ ~r. '
OPERATORS NAME cf:fù.)
. OWNERS NAME ~ .¡.((;.)
NAME OF MONITOR MANUFACTURER
DOES FACll.1TY HA VB DISPSNSER PANS'?
I
\bB\<ri1)"F"\ Fl Û£ Cj4-
I
I
-
OG...)~ -('Qt'<!\ln(; ]SL:;L-~
YES_ N0H
TANK#:
.\
VOLUME
J(9l DOD
I () ¡ODD
CONTENTS
~ "
~..
. .
. .. - ,-.-: ~
NAME OF TESTING COMPANY-., RI~H iNVIRONMEN~ð.L
CON'tRACTORS UCBNSE # 9 0-1 0 72
NAME & PHONE NUMBER OF CONTACT PERSON JAMES R XCii 1661) :3 9 2 -$ 6 87
, , .
DATE & TIME TEST IS TO BE CONDU~ . i OJ ¡ d I o""¡ - q: Cùi\ V'Y) ~ :
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APPR.ovm> BY
'1/:;-1/0 .¡
DAtE.
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SIGNATURE O~ APPUCANTj .
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