HomeMy WebLinkAboutUST-MONITORING SYS. 2/13/2004
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6630 Rosedale Hwy" # B, Ba ersfield, CA 93308 Phone (661) 588-277~ (661) 588-2786
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MONITORING SYSTEM CERTIFICATION
This form must be used to document testing and servicing of monitoring equipment. A separate certification or report must be
prepared for each monitoring system control panel by the technician who performs the work. A copy of this form must be provided to
the tank system owner/operator. The owner/operator must submit a copy of this form to the local agency regulating UST systems
within 30 days of test date.
A. General Information
Facility Name: L \íH I A rJ\ ~c::; A~\ Bldg, No.:
Site Address; ?\ \ 0 \ c'fltU.dtll}l. City: ~~.-E"{2'"S.'F \ Ël.D Zip; -133,3
Facility Contact Person: Contact Phone No.: ( bb \ ) '3<:\8 ' 0261../
MakeIModel of Monitoring System: 8Y\C / PAo?Crl0 11001.. A Date of Testing/Servicing; LI.J.3,.J~
B. Inventory of Equipment Tested/Certified
Check the a ro r¡ate boxes to Indicate 5 ec:lflc: e ul ment Ins ec:tedlservlc:ed:
Tank ID: \ )roJ l ç A \)~ ~
~n· Tank Gauging Probe. Model: p,~('\ 7 b Soq h 0 \ 0 D
o Annular Space or Vault Sensor. Model:
o j;'iping Sumt> lTrench Sensor(s). Model:
~_SumpSensor(s). ~-rr Model:Oì9438c-1.oq
c:i.-1'VIechanical Line Leak Detector. Model: (lØ JACI4:T' lib- ot "t-
O Electronic Line Leak Detector, Model:
o Tank Overfill! High-Level Sensor. Modei:
o Other s ecif e ui ment e and model in Section E on Pa e 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). Model:
o Mechanical Line Leak Detector, Model:
o Electronic Line Leak Detector. Model:
o Tank Overfill / High-Level Sensor. Model:
o Other s ecif e ui ment e and model in Section E on Pa e 2 .
Tank ID:
o In-Tank Gauging Probe. Model:
o Annular Space or Vault Sensor. Model:
o Piping Sump I Trench Sensor(s). Model:
o FiI1 Sump Sensor(s), Model:
o Mechanical Line Leak Detector. Model:
o Electronic Line Leak Detector. Model:
o Tank Overfilll High-Level Sensor. Model:
o Other s ecif e ui ment e and model in Section E on Pa e 2 ,
Tank ID:
o In-Tank Gauging Probe. Model:
o Annular Space or Vault Sensor. Model:
o Piping Sump l Trench Sensor(s). Model:
o FiI1 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 ecif e ui ment e and model in Section E on Pa e 2 .
Dispenser ID: Dispenser ID:
QYDispenser Containment Sensor(s). Model: (;JL1 i..{ ~ ?ò- '2 ('¡ <1 0 Dispenser Containment Sensor(s). Model:
~hear Valve(s). 0 Shear Valve(s),
o Dis enser Containment Float s and Chain s . 0 Dis enser Containment Float s and Chain s .
Dispenser ID: Dispenser ID:
o Dispenser Containment Sensor(s). Model: 0 Dispenser Containment Sensor(s), Model;
o Shear Valve(s), 0 Shear Valve(s).
o Dis enser Containment Float s and Chain s . 0 Dis nser Containment Float s and Chain s .
Dispenser ID: Dispenser ID:
o Dispenser Containment Sensor(s). Model: 0 Dispenser Containment Sensor(s). Model:
o Shear Valve(s). 0 Shear Valve(s).
ODis enser Containment Float s and Chain s . 0 Dis enser Containment Float s and Chain s .
·If the facility 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 inspectedlserviced in accordance witb tbe
manufacturers' guidelines. Attached to this Certification is information (e.g. manufacturers' checklists) necessary to verify tbat this
information is correct and a Plot Plan showing the layout of monitoring equipment. For any equipment capable of generating such
reports, I bave also attac~d a copy of the report; (ChU. k all that apply): 0 S~m ~t-'fP 0 Alarm history report
Teclmician Name (print): t- \ DEL C,qQfZ,LLQ) Signature: ~.Ð.i C(;. 9..~<2-.AÁA..i~
Certification No.: \Oð~ LI License. No.: ?. -=f -z.8 I;¡
Testing Company Name: ß S5 R INC. Phone No,:( bb\ ) 58:8'?-"'71-=1
Site Address: 66~c::> R 0 'S. ~ DA Lt: 1-\ \¡J,\( ~ [3 Date of Testing/Servicing: LI!3_jQ.!:L
Page t of 3
03/0t
Monitoring System Certification
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Q~; Results of Testing/Servicing
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Software Version Installed:
Ib.O 5
Com lete the followin checklist:
GVY es 0 No· Is the audible alarm 0 erational?
C3"'Yes 0 No· Is the visual alarm 0 erational?
CiV"Yes D No· Were all sensors visuall ins ected functionall tested, and confirmed 0 erational?
5{"Yes D No· Were all sensors installed at lowest point of secondary containment and positioned so that other equipment wil1
not interfere with their ro er 0 eration?
No· If alanns are relayed to a remote monitoring station, is all conununications equipment (e,g, modem)
N/A operational?
For pressurized piping systems, does the turbine automatically shut down if the piping'secondary containment
monitoring system detects a leak, fails to operate, or is electrically disconnected? If yes: which sensors initiate
positive shut-down? (Check all that apply) GJ-Sumptrrench Sensors; Qt.-6ispenser Containment Sensors.
Did ou confum ositive shut-down due to leaks sensor failure/disconnection? Ci-Yes' 0 No.
D No· For tank systems that utilize the monitoring system as the primary tank overfill warning device (i.e. no
D N/A mechanical overfill prevention valve is installed), is the overfill warning alann visible and audible at the tank
fill oint s and 0 eratin ro erl ? If so at what ercent of tank ca ad does the alann tri er? %
Was any monitoring equipment replaced? reyes, identify specific sensors, probes, or other equipment replaced
and list the manufacturer name and model for all re lacement arts in Section E below.
Was liquid found inside any secondary containment systems designed as dry systems? (Check all that apply)
D Product; 0 Water. If es descnoe causes in Section E below.
D No· Was monitorin s stem set-u reviewed to ensure ro er settin s? Attach set U
es D No· Is all monitorin e ui ment 0 erational er manufacturer's s ecifications?
* In Section E below, describe how and when these deficiencies were or will be corrected.
DYes
o
[f¡I
o No·
o N/A
Yes
Yes
DYes·
~ No
DYes·
&! No
E. Comments:
Page 2 of 3
03/01
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F. InJfank Gauging / SIR Equipment:
o Check this box if tank gau.s used only for inventory control.
o Check this box if no tank gauging or SIR equipment is installed.
This section must be completed if in-tank: gauging equipment is used to perform leak detection monitoring.
Complete the foUowinl! checklist: '
Qi(Yes CJ No· Has all input wiring been inspected for proper entry and termination, including testing for ground faults?
CYYes CJ No· Were all tank gauging probes visually inspected for damage and residue buildup?
c:f'Yes CJ No· Was accuracy of system product level readings tested?
GY Yes CJ No· Was accuracy of system water level readings tested?
GVYes CJ No· Were all probes reinstalledproperJy?
GYYes CJ 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.
G. Line Leak Detectors (LLD):
o Check this box if LLDs are not installed.
Complete the foilowill2 checklist:
: !3"'"Yes 0 No· For equipment start-up or annual equipment certification, was a leak simulated to verify LLD perfonnance?
o N/A (Check all that apply) Simulated leak rate: IJI.-1 g.p,h,; 00.1 g.p.h; Q 0.2 g.p.h.
e--yes o No·
B" Yes' o No·
G;YYes o No·
CJ N/ A
DYes o No·
~ N/A
DYes o No·
~ NfA
o Yes o No'"
~ N/A
a Yes Q No'"
r;¡ N/A
G}'ý es CJ No'"
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Were all LLDs confirmed operational and accurate within regulatory requirements?
Was the testing apparatus properly cahòrated?
For mechanical LLDs, does the LLD restrict product flow if it detects a leak?
For electronic LLDs, does the turbine automatically shut off if the LLD detects a leak?
For electronic LLDs, does the turbine automatically shut off if any portion of the monitoring system is disabled
or disconnected?
For electronic LLDs, does the turbine automatically shut off if any portion of the monitoring system
malfunctions or fails a test?
For electronic LLDs, have all accessible wiring cOImections been visually inspected?
Were all items.on the equipment manufacturer's maintenance checklist completed?
* In the Section H, beJow, describe how and when these deficiencies were or wj]] be corrected.
H. Comments:
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Monitoring System Certification
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Site Address:
UST Monitoring Site Plan
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Date map was drawn: LlJ.3.JQ.~.
Instructions
If you already have a diagram that shows all required information, you may include it, rather than this page, with your
Monitoring System Certification. On your site plan, show the general layout of tanks and piping. Clearly identify
locations 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 leak
detectors; and in~tank liquid level probes (ifused for leak detection). In the space provided, note the date this Site Plan
was prepared.
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