HomeMy WebLinkAboutUST-MONETORING SYST CERT. 10/11/2004
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MONITORING SYSTEM CERTIFICATION
. . For U$e By Al~ Jurisdictions Within the StClle of C(¡Jifornia
.-1¡¡¡homy CJï~d: Choprer 6.7, Healfhand SCljety Code; Chapter 16, Division 3, TiTle 23, CaJifòrnia Code ofReg¡.¡/(I{ions
;i
'~'l1is iûnn mus. b~ used £0 document testing and se 'vic~n~ of monitoring equipment. A separate certification or report must be ?I'epared
rof çjdl mOlìHOl'Ult!. system control panel by· the œChmClafi who performs the work. A copy of this form must be provided to the tank
sysklll ownerJopera£Or. The owner/operaror must submír a copy of this form to the local agency regulating UST systems within 30
lid);; of lcst darç.
A. Gcfiëralluformatiou
Facility Name:~.....i 1'1,.) ('7 d
SiT¡: ."..ddress: ,)lt0 I t<../HITE ¿ 'L1
r,lcil1¡y Comac¡ Person: '4$ JJ-{J-412-
IVIM~(:·Modèl of Monitoring System: ì'--ò - Jø
Bldg. No.:
City: g4XF ~PI¡;l.J 0 Zip:
Contact Phone No.: ( )
Date of TestinglServicing: -lð...I.l.L_..I~<;Z
B. lHveilto1"Y of Equipment Tested/Certified
. Çlj-",,¡~ d,< ."2£/·Ù ¡-j¡¡¡e boxes ro indicare S céÌtic C ljÎ menr_ins )ecred/sel"vic;cà;
II T ¡ìJ) IL LD: _-.JLA..J L ~ 7
I' 'ï11n-bnL Gaug.ing Probe. Mo(kl: f'1~
~ A,mlular Spacè or Vault Sensor. Model: ',-/,,0
\ ~ Piplllg Sump / Trench Sensor(s). Model: 'Ø-O f{
~ fïU Sump Sensor(s). Model: .}O~
o J\lcduuJical Line Leak Deœctor. Model:
o EkcIrollic Line Leak Dè¡eclùr. Model:
o Lû1k OVèrfiJl / High-Level Sensor. Model:
o ºlh~r lS ecil\' è( ui ment l' e and model in Sterian E on Pa)e 2).
'Lwk ID:
o In-1'::Ulk Gauging Probe. Model:
o _"'-!lJllllar Space or Vault Sensor. Model:
o Piping Sump ¡ Trench 5ensor(s). Model:
I 0 FiJl SUJ!1p SeHsorls). Model;
o i'lk.;;h'\J1ic,Ü Line Leak. Derector. Model:
o Ekcnùllíc Lint Leak. Detecror. Model:
Obnk OVèffijj / High-Level Sensor. Modèl:
o ùl!ler lS èCit\' è'( ui mtm IY e and mod.;! in Sterian Eon Pae 2 .
ItJO
Tank lD: PtU:~ ø¡ /
)( In-Tank Gauging Probe. Model: ¡.1~ /
o Annular Space or Vault Sensor. Model:
)iiI Piping Sump I Trench Sensor(s). Model:
~ FiJI Sump Sen50r(s). Model:
o Mechanical Line Leak Detecror. Model:
o Electronic Line Leak Detecror, Model:
o Tank Overfill I High-Level Sensor. Model:
o Olher (s eCÎ" e ui ment t e and model in Secrion E on Pa e 2).
Tank ID:
o Ifi- Tank Gauging Probe. Model:
o Annular Space or Vault Sensor. Model:
o Piping Sump I Trench Sensor(s). Model:
o FilJ Sump Sensor(s). Model:
o Mechanical Lifle Leak Detector. Model:
o Electronic Line Leak Detector. Model:
o Tank Overtìll J High-Level Sensor. Model:
o Others eci e ui ment e and model in Section E on Pa" e ~). .__
Dispenser lD: r 51
Ii' Dispenser Containment Sensor(s). Model: ð<::'f
:tiit Shear Valve(s).
o Dis enser Containment Float(s) and Chain(s).
Dispenser lD:
þ( Dispenser Containment Sensor(s). Model: &
jtShear Valve(s).
o Dis enser Conraìnmenr Floar(s and Chain(s).
Dispenser ill:
o Dispenser Conrainmenr Sensor(s). Model:
o Shear Valve(s).
o Dis enser Containment Float(s and Chain(s .
Include information for every tank and dispenser at the facility.
~~
Dispenser lD: 1- ~
~ ~i~ptnsèr .Conrainmem Sensor(s). Model: õ-C'~
fA. ;)!¡ç,'\r \, ,ìlvç(s).
.º.J)j.Sl~dlsér Comainmenr Floal(s) and Chain(s).
DispèJlser 1Ú:
!}{ Di,,;pèlber COmainl11ènI Sensor(s). Model: dO - ~
I ~ She,u' V,Üye(s).
o Dis.fJèrb~r COl1lainmem Floû¡(s) and Chain(s).
ûispensér 1D:
o Disp0lbèr Comuinmenr Sensor(s). Model:
o ShC;,(f Valve(s).
ODj~ èn~èr .Conrainmem Floar(s) and Chain(s).
'lflÜe ÙcilÌly contains more tanks or dispensers, copy ¡his tòrm.
C. Cèrtification -1 certify that the equipment identified in this document was inspected/serviced in accordance with the manufacturers'
guiddilles. A£tàcbed to tbis Certitication is information (e,g, manufacturers' checklists) necessary to verify that this informatioll is
êOrr¡;C[ àud à Plot Plan showing the layout of monitoring equipment, For any equipment capable of generating such reports, 1 have also
_', . ;¡.{(¡jêb"d a copy o~' the re~3r& SfhJ;!~k aJl 1/J(lBPl:~V)j ÞI system. ~et-up ~ ~. rro history report
1 èdlfllClan Name (pnm): ~V M~J(./ Signature: __ ~ . _
Cc:nÜÌ<:mion No.: OOf.9· QS 9 I)"" License. No.: 1/D40- if ~'p9850
Tc:srlng Company Name: RICH ENVIRONMENTAL Phone No.:(661 ) 392-8687
SirUì.dcJrtss: ~} '^-' tJ,~ LA) l1~g4J¡::-1¡;L-t4 t"4- Date of Testin?)Servicing: ..-h:!./ _!L_j~Z'-.
Page 1 of3
03/01
MùüÜoring Sy~tem Certi1ïcatioß
"I
~'i. f
D. ä.èSUlls of Testing/Servicing
Soil'll 'ìJ': V è rsion Installed: \ 'ð) \ ð Ò
CÙÚi )1':(l: (he followin<> chec\dist:
I· ~ Y èS 0 NO:: Is rhe audible alarm 0 erarional?
. \~ UNo" b the visllal alarm 0 erational?
!l1 y~:s 0 No* Were all sensors visuall ins eeted, functional! tested, and confirmed 0 erational?
'l:i Yc.S 0 No* Were all sensors installed allowesr point of secondary containment and positioned so that other equipment will
nor interfere with their 1'0 )er 0 eration?
If alarms are relayed to a remote monitoring station, is all communications equipment (e.g. modem)
operational?
For pressillized piping systems, does the turbine automatically shut down if the piping secondary containment
monitoring system detects a leak, tàils to operate, or is electrically disconnected? If yes: which sensors iniriate
posirive shur-down? (Check all ¡hac apply) ~ Sump/Trench Sensors; 'ijI. Dispenser Contai,Ullenr Sensors.
Did IOU confirm ositive shm-down due to leaks and sensor failure/disconnection? Yes; 0 No.
for tank systems that utilize rhe monitoring system as the primary tank overfilJ warning device (i.e. no
mechanical overtill prevention valve is installed), is the overfill warning alarm visible and audible at thè tank
till oim(s) and 0 eratino ro erly? if so, at what ereent of tank ca aei does the a]anD tri,,<>er? ~'l\
Was any monitoring equipment replaced? If yes, identify specific sensors, probes, or other equipment replaceJ
and !ist the manutàcturer name and model for all re lacement arts in Section E, below.
Was liquid fOlmd inside any secondary containment systems designed as dry systerns? (Check all that apply) 0
Product; 0 Water. If es, describe causes in Section E, below.
\'':$ 0 No* Was monitorin s stem set-u reviewed to ensure 1'0 er settinas? Attach set II licable
Y èS 0 No" Is all monitorína e ui men¡ 0 erational er manufacturer's s ecifications?
" In S¡;CÜOll E below, describe how and when these deficiencies were or wiJJ be corrected,
FC; 0 No"
~N¡A
þYés 0 No"
0 N/A
I
¡Iu ):c-s 0 No"
il ~ N/A
i
0 Yc-$'· ~Nü
U Y.:s* Jt No
£. ÜJú.unencs:
.-..._.---_.._._._---~..
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----~ '"....-. --.----- ----""
----.- --- -~._._---.-._-
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- -----~
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03101
Page 2 of' 3
....
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t·
F. lü-'Cmk Gauging j SIR Equipment:
~ Check th~s box ~ftank gauging.is used only f~r inventory control.
Ó Check thIS box If no tank gaugmg or SIR eqmpment is instalkd,
This sècÜon must be completed if in-tank gauging equipment is used to perform leak detection monitoring.
('ÛiH2.!dê rile îûllowinu checklist'
'k
o Y-:s 0 No'" Has all input wiring been inspected for proper entry and termination, including testing for ground faults?
_.
0 \'ò 0 No" Were all tank gauging probes visually inspected for damage and residue buildup?
U y"s 0 No* Was accuracy of sysœm product level readings tested?
0 YfS 10 No" Was accuracy of system water level readings rested?
U Y'cs 0 No* Were all probes rdnsralled properly?
@_Yd 0 No'" Were all items on the equipmenr manufacturer's maintenance checklist completed?
¡, 1n fÌle Secrion H, below, describe how and when these deficiencies were or will be corrected.
G. Lint Le¡.k Detectors (LLD):
J& Check this box if LLDs are not installed.
elf II . a checklist
Ollll) êh' (It' 0 OWlß~ :
U Yö 0 No'" For equipment start-up or annual equipment certification, was a leak simulated to verify LLD performance?
0 N/A (Check all ¡hm apply) Simulated leak rate: 03 g.p.h.; 00.1 g.p.h; 00.2 g.p.h.
0 Yes 0 No* Were all LLDs confirmed operational and accurare within regulatory requirements?
0 Y'e:; 0 No; < Was me testing apparatus properly calibrated?
0 Yes 0 No; < For mechanical LLDs, does the LLD restrict product flow jf it detects a leak?
0 NlA
U Yes o No* For elçctronic LLDs, does the turbine automatically shut offifthe LLO detects a leak?
o N/A
0 '{es o No'" For electronic LLDs, does the turbine automatically shut off if any portion of the monitoring system is disabled
I o N/A or discormected?
0 'íès o No* For electronic LLDs, does the turbine automatically shut off if any p0l1ion of the monitoring system maltlmcrions
o N/A or fails a rest?
0 Yes 0 No* For elecrronic LLDs, have all accessible wìring connections been visuaJly inspected?
0 NlA
U Yes 0 No'" Were all items on the equipment manufacturer's maintenance checklist completed?
," In (!Ie Section H, below, describe bow and when these deticiencies were or will be corrected,
H. Cû:m.menIS:
-.-...----"-.----
--..---
--------~
----.----
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--...-..-----.-..
Page 301'3
03/01
To,
'Ì '
lviùni'(oriüg Sys[~m Certification
Sirc: A.c1drèss: _ðúð
UST lVlonitoring Site Plan
c.J I!- ~ LV. ~~ (£ a-~ F)b L t1 r 4-
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Dace map was drawn: 10 / ~ !!...:Z.
Instructions
if )0Ü alfèady have a dia.gram that shows all required information, you may indude it, rather than this page, with your
.MonÍlürÜ1g System Ceniììcation. On your site plan, show the general layout of tanks and piping. Clearly identit~'
lüuriollS of rhe 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 lÍlle \ea\\.
dèlècrors; a.nd in-rank liquid level probes (if used for leak detection). In the space provided, note the date this Site Plan
\\ ,1.'; preparèd.
Page ~ Of-.!t-
05/00
Î
.~,~'-... ;:.
!
!
I .
SB989 TEST~~ ~AILURE REPORT
SITE NAME: c,A':J /LJ (7 0
:--.. (.,A..J
DATE: /ð -- J J .--(;/ ý
CITY:
SIGNATURE:
TECHNICIAN:
: \ .
THE FOLLOWING COMPONENTS WEIΠItEPJJACED/REPAIRED TO COMPLETE THE SB9S9
TESTING.
LIST OF PARTS REPLACED/REPAlREÐ:.
. .
REPAIRS:
- .oOJF"
LABOR:
.ÆJ(jJ() F
PARTS INSTALLED:
/{jeJ /Uf:
. -
. _.~~,;~~ ".
,:::;\VK,-~, hnuary 2002
;.~,...-'-~'
Page -1- of d.._n
Secondary Containment Testing Report Form
7'11 is /Òrm is intended for ~Ise by contractors performing pertodi~ testing of UST secondary containmsnt systems. US(2 thi4
ilpprc¡priare pages of this form to report ,'esultsfor all components teated. The completedform, written test procedures, and
p¡,jmO¡¡iS jì-om iests (if applicable), should be provitkd to tJw facility owner/operator for submittal to the lo~al regulato", agency.
1. FACILITY INFORMATION
If Facility Nalllè:' .
I~-:.f:acilit);-¡ddress: '
I-·_··'"--~
I FaciliTY Contact:
i~---'
It Dale.: Local Agency Was Notified of Testillg :
\ .i'lm::'ê ot Loca.l Agency Ins ector (ifpresent during te.stin.
£.,J\)
r_S~?!l~j;~ny 1~~n~~:RI~~ ENVIRON~ŒNTAL 0
fT"IUÜcian Co,_tillg Test: e<¡ A-U r1 ~ o-tJ
1. Credèm:ials: 18 CSLB Licensed Contractor 0 SWRCB Licensed Tank Tester
Lla!lSe Type. C611D40 ! License Number: 809850
.....~"~~,:.'M.....':)}'{t,~~..~~..,~I{?.f.~- ,
t Ma,~~ Tr¡iging
I ____ Manufacturer . ConmOllentl':Ù Date Trainíne EXDires
INCON INCON TS-STS 8/04
1-'- -.---.
t- o
2. TESTING CONTRACTOR INFORMATION'
¡-- Component Pass Fiji Not B.epairs COUlponent Pass Fail Not Repairs
Tested Made Tested Made
1------ ~ 0
I _~~-ì 'F/f.,L t1øx 0 0 0 0 0 0
I
I
1.elF"" 9/ ~tLL ~~ ~ 0 0 0 0 0 0 [j
0 0 0 0 0 0 q [J
IL_.________
0 0 0 0 0 0 0 0
~------ 0 0 0 0 0 0 0 ,0
I
¡r-.------.-----.... 0 0 0 0 0 0 0 0
r-·----· 0 0 0 0 0 0 0 0
0 IJ 0 0 0 0 0 0
1------ 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 0 0
--.. -
3. SUMMARY OF TEST RESULTS
If l1vdrostatic testing was performed, describe what:was done with the water after completion of tests:
- .
RECYCLE AND REUSED
, .
-,---~_._---_.
C:F:RTlFICATION OF TECHNICIAN l\ESPONSmLE FOR CONDUCTING TBlS TESTING
]~) tite best vfmy kllOwledge, tile facts stated in tlals documant aTf~ accurate and ¡nfull complialU:8 with kg41 Tllqulrlll¡lUmts
Zy L/7b\/ Date: IO-fJ-Oý
Technician's Signature: ,. TJ I ~ I~~ .
---I
i :~.,.
~':..:?> ;
...
;S~~, RCG, January 2002
Page ~ of -d...
9. SPILL/OVERFILL CONTAINMENT DOXES
[f~a~-.i.lit). I is NO~-E~uì~ped Wi.th Spill/Overfill Containment Boxes 0
LSpil.u~).veEfi!!.C9ntamment Boxes are Present, but were Not Tested 0
i;:5l1vlethod Developed By: 0 Spill Bucket Mariùf'acturer
o Other (SpeDify)
o Pressure
o Other (SpecifY)
INCON TS-STS
»a Industry Standard
o Professíonal En¡incer
-. -"_.---------._---
Tèsll\llèlhod Used:
o Vacuum
ISI Hydrostatic
-.-.~._-'---"-'
'[\;:s( Equipment Used:
[~]~L
r:l~~-~i~c,t Depth:
1_......----.-.---
¡Wai.I time. b. ètwe.en applying
pr.;:ssureJvacuum/water and
!' S[anln~ test:
I--~'-'--'--><-
l'est SJ:al1 Time:
E . pment Resolution: . 000 in.
S~itl Box #
Spill ox #
lniÜal Reading (Rr):
Test End Time:
Final Reading (R¡:):
Test Duration:
I ëïmnge in Reading (R¡:-Rr);
Pass/Fail Threshold or
Criteria:
T.eslt UesuH:
J() ~I 0
--- --
.OOð,,J
Pass 0 Fail
o Pass 0 Fail
o Pass 0 Fail
C ôn:uuents - (include information on repairs made prior to testing, and recommended follow-up for failed tests)
.__.----_.~._--.-
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,p', '
- ~
MONITOR CERT. FAILURE REPORT
SITE NAME: (7 A-~ ...u C~ ()
ADDRESS: 'lJ
CITY: SIGNATURE:
SITE CONTACT: ß ~ (j~
THE FOLLOWING COMPONENTS WERE REPLACED/REPAIRED TO COMPLETE THE MONITOR
CERTIFICATION TESTING,
LIST OF PARTS REPLACED/REPAIRED:
REPAIRS:
.ÆJð{j E:
LABOR:
-
/tJO'f: )~
PARTS INSTALLED:
..vo1./'j;
SOFTWARE REVIS10N LEVEL
VERSION~ 123 :'02
SOFTWARÈ~~ 345123~100-C
CREATED - 02.11,25,15.17
NO SOFTWARE ¡"\ODULE
SYSTEr"l FEATURES:
PERIODIC IN-TANK TESTS
ANNUAL IN-TANK TESTS
SY8TEI"1 8ETUP
- - - -
OCT 11. 2004 1:59 PM
SYSTEI"\ UN I TS
U.S,
SY8TEI"1 LANGUAGE
ENGLISH
SY8TEt'1 DATE./TII"IE FORt"tAT
MON DD YYYY HH:MM:SS xM
i GA8-N-GO
2601WHlTE LN
BACKERSFIELD.CA
1-661-833-8553
SH I FT T I/"1£ 1 DISABLED
SH I FT T II"lE 2 D I 8ABLED
· SHIFT 1'11"1£ 3 DISABLED
I SHIFT TIME 4 DISABLED
TANK PER TST NEEDED WRN
DISABLED ,
TANK ANN TST NEEDED WRN!
DISABLED '
LINE RE-ENABLE METHOD
PASS LINE TEST
ILINE PER TST NEEDED WRN
DISABLED
LINE ANN TST NEEDED WRN
DISABLED
PRINT TC VOLUMES
ENABLED
TEt'lP COI"lPENSATION
VALUE (DEG F): 60.0
STICK HEIGHT OFFSET
DISABLED
DAYLIGHT SAVING TIME
DISABLED
SVSTEr"l SECUR I TY
CODE : 000000
CUSTOl1 ·ALARt1 LABELS
DISABLED
IN-TANK SETUP
------ -
T 1 :PREM
PRODUCT CODE
THERt'lAL COEFF
TANK DIA/"tETER
TANK PROFILE
FULL VOL
, 2'
; . 0007001
11 4 . 00
1 PT
8000
FLOAT SIZE:
4.0 IN.
WATER WARNING : 2.0
HIGH WATER LIMIT: 2.5
MAX OR LABEL VOL: 8000
OVERFILL LIMIT 90%
7200
HIGH PRODUCT 89%
7120
DELIVERY LIMIT 10%
800
LOW PRODUCT : 1500
LEAK ALARM LII"II T : 99
SUDDEN LOSS LII"1lT: 99
TANK TILT 0.001
PROBE OFFSET 0 . 001
I
I
SIPHON MANIFOLDED TANKS I
T~: NONE ¡
LINE MANIFOLDED TANKS .
T~: NONE
I
I
LEAK MIN PERIODIC: 0%
0\
LEAK MIN ANNUAL 0%
o
PERIODIC TEST TYPE
STANDARD
ANNUAL TEST FAIL
ALARJ"1 DISABLED
PERIODIC TEST FAIL
ALARt'! DISABLED
GROSS TEST FAIL
ALARt'! D I SASLED
ANN TEST AVERAGING: OFf'
PER TEST AVERAGING: OFF
¡
TANK TEST NOT I FY : OFF I
TNK TST SIPHON BREAK :OFF'
DEL I VERY [)ELAY
PUt'lP THRESHOLD
1 1"11 N
10.00%
\
PERIODIC TEST TYPE
STANDARD
ANNUAL TEST FAIL
ALARI1 D I SASLED
PERIODIC TEST FAIL
ALARt1 D I SASLED
GROSS TEST FAIL
ALARI1 D I SASLED
ANN TEST AVERAGING: OFF
PER TEST AVERAGING: OFF
TANK TEST NOT I FY : OFF
TNK TST SIPHON SREAK:OFF! L 7:DISP 5~6
TRI-STATE <SINGLE FLOAT}
DELIVERY DELAY 1 MIN CATEGORY: DISPENSER PAN
PUMP THRESHOLD 10.00~
T 2:UNLEADED
PRODUCT CODE
THERMAL COEFF
TANK DIAMETER
TANK PROFILE
FULL VOL
: 1
: .000700
114,00
1 PT
12000
FLOAT SIZE:
4.0 IN.
WATER WARNING : 2.0
HIGH WATER LIMIT: 2.5
t'lAX OR LABEL VOL:
OVERFILL LIMIT :
HIGH PRODUCT
DELI VERY L I M I T
12000
90%
10800
89%
10680
15%
1800
3000
99
99
0.00
0.001
LOW PRODUCT :
LEAK ALARM LIMIT:
SUDDEN LOSS LIMIT:
TANK TILT
PROBE OFFSET
SIPHON MANIFOLDED TANKS
T~: NONE
LINE MANIFOLDED TANKS
T~:' NONE
LEAK MII~ PERIODIC:
LEAK !'H.,N ANN~ ~"'."
!" .
. 0%
o
LEAK TEST METHOD
- - - - - -
TEST WEEKLY : ALL TANK
SUN
START TII1E 12: 00 AI"I
TEST RATE : 0 . 20 GAL'HR
DURATION : 2 HOURS
TST EARLY STOP:DISABLED
LEAK TEST REPORT FORMAT
NORI"!AL
- - - -
LIGUID SENSOR SETUP
- - - - - - - - - -
L 1 :91TRUBINE
TRI-STATE (SINGLE FLOAT)
CATEGORY : STP SUMP
L 2:91FILL
TRI-STATE (SINGLE FLOAT)
CATEGORY : PIPING SUMP
0%
o
L 3:87TRUBINE
TRI-STATE <SINGLE FLOAT}
CATEGORY : STP SUMP
L 4:87 FILL
TRI-STATE (SINGLE FLOAT)
CATEGORY : PIPING SUMP
L 5:DISP 1~2
TRI-STATE (SINGLE FLOAT>
CATEGORY : DISPENSER PAN
L 6:DISP 3Ì1E4
TRI-STATE (SINGLE FLOAT)
CATEGORY : DISPENSER PAN
L, 8:DISP 7ìoE8
TRI-STATE <SINGLE FLOAT}
CATEGORY : DISPENSER PAN
L 9:ANNULAR
TRI-STATE <SINGLE FLOAT}
CATEGORV : ANNULAR SPACE
OUTPUT RELAY SETUP
_ _ _ _ _ 3 _ _ _
f/ , .
R l:UNLEADED SHUT-DOWN
TYPE:
STANDARD
NORt"tALLV CLOSED
LIQUID SENSOR ALMS
ALL :FUEL ALARt"¡
ALL:SENSOR OUT ALARM
R 2:PREI"¡ SHUT-DOlJN
TYPE:
STANDARD
NORt"IALLV CLOSED
LIQUID SENSOR ALMS
ALL: FUEL ALARI"¡
ALL:SENSOR OUT ALARM
RECONCILIATION SETUP
- ----
-----
ALARM HISTORV REPORT \
---- IN-TANK ALARM --~
T 1 :PREM
LOW PRODUCT ALARM
OCT 3, 2004 8:29 AM
APR 10. 2004 11-:035 AM;
FEB 24, 2004 10:84 PM
INVALID FUEL LEVEL
SEP 9, 2004 4:30 PM
AUG 10, 2004 5:42 PM·
JUL 20, 2004 7:54 PM
.;,····1·
PROBE OUT
OCT 13, 2003 9:19 AM
OCT 10, 2003 3:02 PM
ALARM HISTORY REPORT
---- IN-TANK ALARM
T 2:UNLEADED
LOW PRODUCT ALARM
OCT 3, 2004 6: 48 PI1
BEP 19, 2004 8:30 AM
BEP 6. 2004 1:51 PM
INVALID FUEL LEVEL
BEP 2, 2004 6:13 AM
AUG 25. 2004 6:08 PM
AUG 2. 2004 1:51 PM
PROBE OUT
OCT 13. 2003 9:18 AM
OCT 10. 2003 3:03 PM
DELIVERY NEEDED I DELIVERY NEEDED
SEP 18. 2004 6:04 AM OCT 6. 2004 12:37 PM
SEP3. 2004 4: 44 PM ¡ BEP 21. 2004 6: 46 P!"I
AUG 18. 2004 8:45 PM I BEP 9. 2004 5:31 PM
LOW TEMP WARNING LOW TEMP WARNING
OCT 10. 2003 3:22 PM OCT 13. 2003 12:07 PM
AUTOI"IATIC DAILY CLOSING
T II"IE : 2 : 00 At"¡
~ ~ ~ ~ ~ END ~ ~ ~ ~ ~ ~ ~ ~ ~ END ~ ~ ~ ~ ~
i PERIODIC RECONCILIATION I
1"10DE: MONTHL ~
, TEMP COMPENSAT I ON
STANDARD ,
BUS SLOT FUEL 11ETER TANK:
- - - - - - - - - - - ~
TANK I"¡AP EI"IPTY
ALARM HISTORY REPORT
----- SYSTEI"¡ ALAR!1 ----.
PAPER OUT "
JUN 22. 2004 11: 44. f'l1"1
PRINTER ERROR
JUN 22. 2004 3:23 PM
BATTERY IS OFF
JAN 1. 1996 8 :00 ~r"1
SYS SECURITY WARNIN~
OCT 10. 2003 2:43 PI"I
~ ~ ~ ~ ~ END ~ ~ ~ ~ ~
ALARM HISTORY REPORT
---1
!
SENSOR ALAR!"!
L 1 :91TRUBINE
STP SUMP
FUEL ALARM
JAN 15. 2004 10:03 AM
ALARM HISTORY REPORT
----- SENSOR ALARM
L 1 :'31TRUBINE
STP SUMP
FUEL ALAR!"!
JAN 15. 2004 10:03 AM
FUEL ALARM FUEL ALARM
OCT 3. 2003 '3 : 20 AI'1, OCT 3. 2003 '3 : 20 Al"1
SETUP DATA WARNING ,SETUP DATA WARNING
SE? 30. 2003 5:47 PM SEP 3D, 2003 5:47 PM
: I
II ALARM HISTORY REP~Rf;
I , .
,
i ----- SENSOR ALARM¡! ;~---
L 2:91FILL . ¡:!'
PIPING SUMP
SETUP DATA WARNIN~
SE? 80. 2008 5:47 PM
'W,I
~
f
11
~'
II
J
~
~
¡
\'
I
~ ~ ~ ~ ~ END ~ ~ ¡~ ~ ~
ALARM HISTORY REPORT
----- SENSOR ALARM
L 3:87TRUBINE
. STP SUMP
, FUEL ALARM
OCT 3. 2003 9:21 AM
SETUP DATA WA~NING
SEP 30. 2003 5·-;-cW-.pr"¡
~ ~ ~ ~ ~ END ~ ~ ~ ~ ~
ALARM HISTORY REPORT
----- SENSOR ALARM -----
L 4:87 FILL
PIPING SUMP'
SETUP DATA WARNING
SEP 80. 2003 5:47 PM
~ ~ ~ ~ ~ END ~ ~ ~ ~! ~ ~ ~ ~ ~ END ~ ~ ~ ~ ~
~ ~ ~ ~ ~ END ~ ~ *
~ ~
ALARI1 HISTORY REPORT
_r..
-----tSENSOR ALAR!"!
L 5:DISP 1",2
DISPENSER PAN
FUEL ALAR!"!
OCT 3. 2003 9:23 AM
FUEL ALAR!"!
OCT 3. 2003 9:23 AM
-._-. -----..
-- ..------=~_.-
- -- - --1-'-'-<-'--
"-"--,-~-
ALARM HISTORY REPORT
----- SENSOR ALARM
L 8:DISP 7:.E8.
DISPENSER PAN
FUEL ALARM
OCT 3. 2003 9:25 AM
FUEL ALARM
OCT 3. 2003 9:24 AM
SETUP DATA WARNING
SEP 30. 2003 5: 47 PI"! SETUP DATA WARN I NG
SEP 30. 2003 5:47 PM
'" ~ ~ ~ ~ END '" ~ '" ~
ALAR!"! HISTORY REPORT
----- SENSOR ALARM
I L 6 :DISP 3",4
DISPENSER PAN
FUEL ALARt-1
OCT 3. 2003 9:22 AM
FUEL ALARt-!
OCT 3. 2003 9:21 AM
~ ~ ~ ~ * END'" '" '" ~:
ALARM HISTORY REPORT
----- SENSOR ALARM
L 9:ANNULAR
ANNULAR SPACE
FUEL ALARM
OCT 3. 2003 9:35 AM
SETUP DATA WARNING
SEP 30. 2003 5:49 PM
. _ J.._4~_._ .:..
ALARM HISTORY REPORT
----- SENSOR ALARM
ç 1:
OTHER SENSORS
----1
----- SENSOR ALARM
L I:91TRUBINE'
STP SUMP
FUEL ALARM
OCT 11. 2004 2:16 P~
,
----- SENSOR ALARM --¡--
L 2:'31FILL
PIPI NG SUt-IP
FUEL ALARM i
OCT 11. 2004 .2:16 PM:
----- SENSOR ALARM
L 3: 87TRUBI NE
STP SUMP
FUEL ALARM
OCT 11. 2004 2:16 PM
SETUP DATA ~JARN I NG
SEP 30. 2003 5:47 PM ----- SENSOR ALARM
L 4:87 FILL
PIPING SUMP
FUEL ALARM
OCT 11. 2004 2:17 PM
'" '" '" '" * END '" ¡,¡ ¡,¡ ¡,¡
ALARM HISTORY REPORT
----- SENSOR ALARM
L 7:DISP 5",6
DISPENSER PAN
FUEL ALAR!"I
OCT 3. 2003 9:24 AM
FUEL ALARr1
OCT 3. 2003 9:23 AM
SETUP DATA WARNING
SEP 30. 2003 5:47 PM
'" ~ ~ ~ ~ END M ~ ~ '" '"
'" . '" ~ . END '" . . ¡,¡ .
ALARM HISTORY REPORT
---- PRODUCT ALARM
F .1 :PREI1
. ~ ~ '" '" END", . '" ~ ""
,
I
ì
I'
I'
I'
I·
I
.i,.V., , :-.,.
cY,-'.
,,¡..
;¡...·,t~
-I" .
"', ,.---,-,...~...:,.
SENSOR ALARr"!
L 9:ANNULAR
ANNULAR SPACE
FUEL ALARM
OCT 11.2004 2:18 PM
';.i
----- SENSOR ALARM
L 6:DISP 3JJE4
DISPENSERP~N
FUEL ALARM
OCT 11. 2004 2:19 PM
';"1
'~ I
----- SENSOR ALARM
L 5:DISP I !¡2
DISPENSER PAN
FUEL ALARM
OCT 11. 2004 2:21 PM
----- SENSOR:ALARM
L 8:DISP7*S
DISPENSER PAN
FUEL ALARM .
OCT 11. 2004' 2:23 PM
\
----- SENa~R ~LARM
L 7 :DISP 1~6¡ ,!
.:1 . ~~1~~~t~Il24'PM
..j; fi}~~; , r \
.' i¡~f;'~~U ~:~
'4
~ ~
~~\~
10/18/2004
10:34
6613920621
PAGE
02/13
MONITORING SYSTEM CERTIFICATION
For Use. By.'¡JJ J/J/·i..tdir:tion.f Wìthl'l the StO/1l ofCa)iforniQ
;11.aIJOrícy Cited: Ch.lprer 6.7, Healm and Sqfàty Code; Chapter] 6, DM.rian 3, Tì1;e 23, ÇQ1JfomlQ ÇoM of RegU/Qlìon.s
-~'b~ r~1rlU mUst be used 10 docWJ:\&:\'It. testiIlg and set'vlcio~ ofmonitorin¡ equipment. ABlJsrate certification or reR0rt mLl~t ~ Dl'epal'~d
iq,r,£,;J.i,;!U1\pnltodrlli. sween, control panel by the t~chnll~lan who. perfonns the worle. A copy o(this form m\lst be provideå to the tiink
syst~m o\\'ner/opel':ltol'. The owncr/opcJ'IItor must submit Il copy of this form to the loclll agency regulating UST sysre.ms within 30
J~IYs uf lese datt:.
A. Gcnerallnformation
F adlil)' Name: C'J.-1..5 ,v ('.,.'
SlT~ Address: .1ú.O I «/Ñ.I.TE ¿~_
hciliT) ('On1io1Cl Person: ~
M:.\I.:c!ilvJ,adel of Mo.nitoring System; L~.
B. inventor)' of Equipment TestedJCertiíled
Cued. lilt' II ru .'idle b( scø fa icdiutc! S C!eln~ e J cnC!llt lkU )~Ctcd/sl:rvíC:l!d:
City: ~1Jil..,O
Contact Phol1e No.: ( t
Date of Te~tinglSt'r"icing;
B1dg. No.:_...___.
Zip:
....Ið.l LL.! 52.Y
()
'1'l1nl.lj): tJlfJLj7 Taok1D: .£U~Ð /
11\..1\11\1;. O~gil\g Probe. Mßdëï;-' t1~L - ~ in-Tank Gø.\¡ging ProCe, Model: IN'JdþL..____
AtUHllar Spl1~ or Vault Sensor. Mod~l: '''¡¡''O Q Annular SPI\CC or Vault Sensor. Model:
Piping Sump I Trcnch Scnsor(s}. Model: -q." r 'JI Piping Sump / Trench Sensor(s), Model; -~~
,. ¡:j J $lIJI)P Sel'1Sorls), Mode!: >OTs": )! Fill Sump Scnsor(s). Model: ~~
o ~l.:ch~ulical Line L.:ak Detector. Mocl~l; 0 Mechanical LÌJ1e L~aI, Detecror. Model:
Q i:!~I.'t1\-'[lÌ~ l.jù~ L~1lk DeT~C[O '. Modci: _~_ C Electronic Line Leak Detcctor. ModeJ:
OTanI.: Ovc:rtiU I High-Level Sensor, Modd: .__ Q TSl1k Overt1111 Hlgh~1Avel Sensor. Modcl:.___
o Orher (s cel c uì mcnr and model in Sec~o." E On Pa c 2 . 0 OtheT s eel . e ul ment r ð and mode] in Sectjon £ on.P1! s: 2 .
T1!1Jl\.lD: Tønk (J);
o 1J1,-'1':,)nl.: Gallging probe. Model; [J In-Tank Gauging Probe. MOdel;
Q Annular Sp3c~ I1r Vault S~llsor. ModeJ: 0 Annular Space or Vault SenSOr. Model;
I 0 PipinJ?, :)ump 11'~nch SÇ4$or(g), Model: Q Piping Sump I Trench Sensor(s). Model:
o FilJ Sump SensOrlS). Modc:l: Q Fill Sump Sen¡¡Qr{~). MOdel:
o Jo,'l.:.;h~'I1)¡O;:IÙ Litle Leak. Det¢l::toe. Model; Q Mechanical Line Leak DeteçtOt. MOdel:
Q I:h:o.:lwnÎC Line Leak Dctcctor. Model: Q E.lectl'onic tine Leak Detr:ctor. Model:
Q Tank O~'crrìlll High-Level So!1lSOr, Molte ; ~_ Q Tank Overfill I High-Level Sensor. Model;
o t..Jeh~J·ls. ~d' «!,!,j m¢m f e and mode] jn Secrion E on Pa e 2 , [J Other s eel e \J! rn~nT I\I1d model in Section £ on Pa' 2).
Di.splrn.s.:r II): .-~_..L::: d- . Dispenser ID: . .
~ Di:lpeHS~CoI1LW11lt~ru: SensOr(9}. Model: )ØY" ~ Dispenser Containment Scnsor(s). Model: dðf
~ SJj~ar V¡¡I\I~(j). 'B Shear Valve(s).
o I)h 11:1)$':1' C()L1faJnmenr floa, S IU1d Cha.in{s). 0 Dis enser Conlllinment Floar sand ChDÎn s),
Di$pl!J1s~.· ill: Dispenser 10:
j( Disp~Jlse( Cómai11Inã1[ Sen~or(s). Model: ð<?' k': þ(' Dispenser Containment Sensor(s), Model:
I ~ Sh~¡u' VIIL\-e(5,!. jit Shear Valve(s),
o Dis cnscr COI1I;tÙ¡mtò¡ Floilr s and Chain s , [J Dis enser Containment FlolIt s and Chain s ,
J)¡sp(,/lsl!,.lD:_.~...__._.._~__~_ DispenserID:
a DisPèIIS~)' COnTairunenr Sensol'(s). Model: I:) Dispenser Containment Sensor(!:). Model;
o Sh(~\J: v¡Ù\I¢lS). a Sl\~ar Val'lc{s).
aOi~ n~c!.I' Conu¡iJ1meru Jô'lou 9 and ChaÌJ1 s . Q PJs enser Containment Float(s and Chain s .
-1t'111.: thcilÜ)' contains more tanlcs or dispensers, copy this fOI'I\1.. Ù\ctud" information for every rank IWd dispenser lit the facility.
C, Cèrtific¡:¡tion -I tertlfy thAt tile equipment IdentU1ed In this d.ocument was iRtlpected/nrviced in Qctordenee with the maàlll'aeturen'
~uld~linl!s. Arraehtld to tbiJ¡ Certitieatjoll is information (e,g. manufacturers' checklists) necesury to verify that this information Ì$
o:( rnt:t iÌlld .. Plot Plall showing the layout of monitoring eqldpment, For any equipment capable of generating sucb reports, I bDve Illso
òlual:hed a (Opy oCthe re~arQ í~k IJJ! 1J¡~i~)j )I System set·up ~rm history report
T~l;hL\Åci:u\ Name (print): ~_t'1~M' SignatUre:' _ ~
Cr:I'¡ixì.:ul'Í¡;¡DNo.: O()l9 'o,.r- r)-n Líeense.No,; l/D40- #8.99850 .
T¢þtill~Ctjmpì1nyNflme: RICH :E:NVIRONMENTAL pnoneNo.:(661 ) 392-8687
Sih:' Adúress;: ..~~~t..Zt lAJ. tf.~.ß:íEIÃ.~(Ì ~ Date of TesringlServiçing: ---1d .L1......l~.)!!.
Page lot'3
03/~1
MÜllitoring System CertUication
·"
:r
10/18/2004 10:34
6613920621
PAGE 03/13
D. 1~ðults of' 'resting/Servicing
Soth, ZLl\~ V ~rsion In:ltlilled: J....'t1_~g-..ð
Com It:IC rhi.' i'ollow!n cbecldist:
I ~ y ~s a No· ~ ~ audible alarm 0 eratlof\al?
---:--y~s a No'll Is dlC: visual alarm 0 erational?
œ Y <:s Q No'" Were JI sensors visuaU ins ected functjonal tested. and confim\ed 0 era.tional?
-e Yc:~ 0 Nr,)'" Wen~ all ~eIlSOf$ installed at lowest point of secondary çonmirunent and positioned SO that other equipmen.t wi!!
not interfere with their TO er 0 eratiOn7
If altum~ are relayed to a rcmote monitoring statlon. is all commlmicatioos equipment (c.g, modem)
oper,fltional?
For pl:~ssW'¡zed piping systems, dO~9 the turbine automatically shut down if the piping secondary contaínm~ot
D1onìtoring system åetects n l.eak, &Us to oporate, or is elèccriçeJly disconnected? If)'es: which 5Ienaors ullri;¡\cr:
positive shut-down? (Check all (hut apply) 'i:I SUß1plTrench SenSOI'B~ . Dispenser COlttainmel1c Sens<:)rs.
Did OLl confirm osít.ive shut-down due to leaks and sensor failure/discotUlectîon? Yes; Q No.
For lank systems that utilize the monitoring system as the primal}' tank overfill warning device (i.t. Ill'
luechanjcaJ overfill preVel\t\()ll valve is installed), is the overfill warning alarm visible and audible at the t~l\k
tì.11 oint(s) and 0 eratin to eel ? l£So at what erc~t of tank ca aei doe$ tho alarm trIo er? %
Was iUly monitoring equipn\en.t replaced? It'yes, identify specific sensors, probes, Or other equipm.ent replac~J
and I ¡st the manufacturer name and model for aH re )acement am in Section E, below.
Q \'esli< ~ Nù Was liquid fO\lnd inside aO)l secondary conta.inme~'t $Y5~ms designed as dry systems? {Check (11/ rh", uppJy) I:J
._ .....,,_~ Product; 0 Wat.er, If es, describe caus~ ,n Section E, below.
X'~s a No· Was mon.ito.rin s rem set-u reviewed to ensure to er settjn ? Attach s~t 1.1
'i cs D No"" Is all monitor-in" ¢ ui ment 0 erational er OJaJ1Ll!actllrer's s ccificatiol\s?
.. 1(1 Si:'cJioll [ below, describe how and when these deficiencies were 0.. wiU be corrected.
o y';:,;
Q Nr,)'II
OfN/A
o No"
o N:'A
p.Yc:o
o-\-~~~ 0 N.;,"
11- N/ A
LJ y ~~~
-,Nù
f:. Comm~nts~
"" ........-......
... -.... -..--- ._....
Ucable
--.---..
--_.
u.. ~ _ _. ._...... _.__
__"_"'__~H ,,_____
_.'.. '._____"'__0"'_"'.
..-........-.-.-.-..
....--...........-..--
. .-'" ...,....-.-.-....
--.--..
-..-.-. ---
......" .....---
-.-.....
-- -----
_..~--_....
....NN "._".~,....__.____....
..--
.. .,. ..--- ,.--- --
------..
.....---.-.-...
.............-.--
.P.øRe 2 Qt' J
UJ/öt
.
10/18/2004 10:34
6613920621
PAGE 04/13
f. ÙI-'J'n.nk Gauging I SIR Equipment:
~ Check this box. if tank gal,l.gÎng is lIsed only for inventory contn)I,
t:J Check this box. if. no tank gallging or SIR equipment is ilUtalled.
1his .st:~don must be com.pleted ü in4ank gatlgin.g equipme.nt is used to peofoIl1.11eak detection monitoring.
c
unll)hm:! rhe fullowini!: cbec\;'Ust:
o \'I.!'; o No'" H~ all Input wIring been ill9pected for proper entry IInd termination, lncludi.ng USting for gro..md mults?
1:1 \'~S o No· Were aU tank gauging p.robes \/!sually iMpected for danUige and residue buildup'?
o '{cs o No· Was accuracy of ¡ystero product level readings tested?
~ 1:1 No· Was IlCèuracy of system water level readings tested?
Q y~:; o 'No. Were ,,11 probes reinstalled properly'?
~ÿ<;¡I o No· Wr:r~ aU items on the equjprnðDt manufac.t\JrcT's malnteniU1ce chcçklisc completed?
t~1,-' .. ...
.. lit rile Section ß, below, describe how and wilen these deficiencies were or wiU be correctéd.
~:>. .Line Leuk Detectors (LLD);
po Check this box if LLDs are nO[ imtaJJed.
COIl1IJI~t(' the follow Ins: checkli.9t:
a y~s Q No" For equipment start-up or annua.l equipment certification, was a leak simulated to verify LLD performance'?
o NlA (Ch6Ck a/J Jhlll apply) Simulared leak rate: C) g.p.b.; Q 0,.1 g.p.h; 0 0.2 g.pJt.
o 'it's 0 No" Were all LLDs conflrmed op~ratjonal and accurate within rcguJarory requírements?
o Yf'S 0 No' Was the testing apparatUs properly calibrated?
a YC;$ Q No· For mechanical LLD9, does Ole 1LD restrict prod uct flow jf it detects a leak?
CJ N/A
CJ 'I ~s Q No" For electronic LLDs, does th~ turbine automälica.lly shut off if the LLD detects a leak?
o NlA
DYes o No· For electronic LLDs. does the turbine automatically shut off jf any portion of me monitoring system is disabled
o NI j\ or discoMecud?
o y~s (J No" For electronic liDs, does the turbine automatically shut off if any portion of the mOllitoring system T1U\ltùnctiolls
a N/A or falls 8 test?
I-=-'~ o No'" Fo.r electronic liDs. have all accessible wiring cOMectiOr'l$ been vi.s~lal1y inspected?
o yc;!~
Q N/A
[J 'Ie.:; Q No'" Were all items On the equ¡pm~Qt manufacturer's maintenance checklist completed?
* In (iu: Sterion Ii, below, describe how aßd when these de(¡~ieClcies were or will be corrected.
H. COJllments: '_'_'__'___
-.......-.------
-'.', ----...
~...._-,.,..-
-....-
_...~..-.....__.
If_''-
..---.........-
.--..--..........
----------
--
.--..-.--..,-----
. .....--.----............--.....----............
----
Page 3 of3
(I}!Ul
i
-..-"
,.
....
10/18/2004 10:34
6613920621
Ñl"¡lÜturiug :S)'litem Cllrtit'tcaUOD
SiLt AJdro!s:.1: dúO ,
. _JAJ ø.- ,\fir
f¡J, teð:
PAGE 05/13
UST lVlonitoring Site Plan
4.~ ~-t (£ ~~F J~ 4 r4
:~~ß:
li.1~~~~
6
'f'
'7,
LJ
. ,~.
/t- I T ê"
'L
J
- r:::::¡ .
· .ð. '
'. .
· . ~....., ,
.~.
· 1...-,.1. .
v'
Dare map was drawn: 10 / ....!LI.!!.:z..
Page îot-.!J-
If }OLl ajn~ady have a diagram 1ha:[ shows aH required infonnatìon, you may include it, rather than this page, with yOLlI'
~'l\)I)Ïto.,.·illg System Certi:l:lcation. On your site plan, show the general layout of tanks and piping, Clearly identify
ilJcmiol1s of the folJowing equipment, if installed: monitoring system oontrol panels; sen90ts monitoring tAnk aJ'\l1ular
SpliceS, sumps, dispenser pans, spill containers, or other secondary containment areas; mechanical or electronic line leak
d¡:}t~":T0rs; nod luo(ank Liquid level probes (if used for leak detection). In the spaoe provided, note the date thLq Site PJa.t
\\'àS pr~p~u- ¡)d.
Inst..uctiO.D.8
05JOIJ
l~". '~
~\ 18/18/2884
18:34
6613920621
PAGE 07/13
SWR.C~, ] Lnwaljl 2002
Pap -..L of d_..
Secondary Containment Testing Report Form
T},j~, jÒrfTI i$ il'urmdsdjtJ1' tlSII by tJQflÞ'4lZtøn petførmi:ng pÐ10dk luting q/US'1' IeJ!O-ndØl'Jl co,,~ I')I.Ø8N. V.¡r" 1M
~llJprlJpr iarB pages of thl8 form to report rwullS ¡Dr all Dó1JlPOlWlU teStðd. Thft cømplst44form. writntJ tat prot:ØlÅu'Ð.J. ond
priI7Iou/.Jfi-on! le.st.r (if applicable). shöuJd beprov~d to thef4CUlty øwnflJ"lDpæ1'QIDr fDj" 8ubm~øJ tþ tM JtX:tÙ ,.~~ agÞncy.
1. FAcn.lTY JMKlItl\U..'X'ION
J.!-.:!Hty N~è:
.F~~~~ Add1'C$s: L.;fj
Fad!~~l~t: fZ
P~:'~2.~~ Agency Wu Notlfied. of Tðltlng :
1:-Iamo;: of LQcal AgCDC 1 OdOr ¡ rtUent efuring ¡BJ1
.,
__~aufncturer
INCON
CJ SWRCB Licensed Tank Tcstl:r
Ucense NulD.ber: 809850
M~,,!f¡~[ 1.tfIQiRI
e
eN-81'S
COh'lPODeøt Pass Fail Not Repairs CompoMDt P. ,.ß NGt kop.lrs
Tested Made . Toted Mad.
-----, 111 d
j ILt If C. 2...- t=' J (.. L it d'.Je' 0 0 0 0 0 0
"ð.- - q I J: 11' R.cIVI '.at 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0
-.....-...-
0 0 0 0 0 0 D 0
~- 0 0 ,0
0 0 CI 0 0
.-.----..-...,. 0 0 0
0 0 0 0 0
,..- 0 0 0 0 0 0 0
0
0 0 0 0 0 0 0 0
f.----.~ 0 0 0 0 0 0 q 0
--~ 0 0 Q 0
0 0 0 0
0 0 0 0 0 a 0 0
- 0 0 D 0
0 0 0 0
3. SUMMARY OJ' TEST RESULTS
If hydrostatic terting was ~ed, describe what "'as done with the w.. after completion aftests:
. .. IJ 1
RECYCLE A~D REUSE~~,
.-----
CERTlFlCAnON OF mæNlCIAN RESPONSIBLE FOR. cœmt1C'I'mG nus TlSTING
7'v tJu bØ$l o.r"7J1 k111ifp'!dl~ t1I4f~18 sIJlUd In th181l0lnmlønt I1.rB 4CCIlrølè tUld btft¡.U complÛ111411 """" ,.øJ JYIIq"i~
T"luúc"",', Sign......:~ 11~ )ate: If) -I )-o~
'J;¡¡.
z: '.: -«;
,. '. - . '11
18/18/2884 18:34
6613928621
PAGE 88/13
S WRCB. January 2002
P-ze 2- of-l.
9. SP OV.ERFlLL CQNTA.Jl'(MENT BOXES
Pac\lit . is. Not &: ui eel Wi.th S i11I0\'d11 Containment 'Boxes 0
Spi11l0verfill CQJ1tiI.Ìntner.tBo&eS are PJ.·eSGll1:, 'but were Nat'Iested 0
Të:>t Metho&;\ D~ve'lopcd By; C SpiLt Su.clœt ~r
o Other ~ eci ~
D PreBS~e
o Other 'Specfjjl)
'l'S-STS
R IndUS'D'y Smndard
o Professional BDai.ueer
--,.----.
Tt.':\t M~tbod Used:
o Vacuum
8 liydrostlLtic
.aooin..
Box #
s
xII
l1u<:k~t D~ ~r:
1jl.lck.~~t :Døpch:
\\;~t t~tween apptying
pr~s~¡¡.u·e/vflCUu.mJwater a.ud
~~l"!.~~ test:
rest Start time:
lnit.ïa..l Re.~jng (R¡):
1'I:$r End Time:
Flnal Readil1g eRr):
1" ,"st Duration:
Change in Reading (RrRV:
i>åssJFail Th¡'eshold or
~\:
Test ResuJt:
;)0 """,,v
D hll D FaU
OPus OF.n
..:£ 0 nunent-s - (include in!ðrm4tlon on repair4 made prlt:»' ro testing, lI1Id recommended:[ollfM-uP jòr f.!'lJsd tuta)
.-.--
-----..
-..----..-.
---..-..
-....-...---
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