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Home My WebLink AboutBUSINESS PLAN ......:- ^ " 12/15/2004 09:48 6613252529 CAL VALLEY PAGE 02 MONITORING SYSTEM CERTIFICATION Fo,. Use 8)1 All Juri.,dictions Within the. State ojC.øJlfo1'tJia Authority Cited: Chapter 6.7, Health end Safet)l Code; Chapter 16, Dtvisi()1' 3, Title 23. California Code. olR.egulatiQf'13 This form must be used to document testing and servicing of monitoring equipment. A separate certification or report mtlst be prepared for each monitoring System control panel by the technician who performs the work. A copy oftbis fonn must be provided to the tank system owner/operator. The owner/operator must submit a copy of this form to the local agency regula.ting UST systems within 30 days of test date. A. Genera) Inforan~dion FaeilityName: ~kerrf+t't!/d' C/~ C,yr fá.ýd, Site Addrcss; 'i/~I Tl/ú. vt"'-I..t ,t}z.q. - Facility Contact Person: MaJc:e/Model of Monitoring System:Y-<,t«w-.Ro171 iLS-3s-ø - ß_ Inventory of Equipment Tested/Certified Cheek tile I propriate boxes to Indicate specilic eqlli meat Însp~~tedlservierd: Tlnk ID: I Ç{7 Vi Tank m: ~ rn-TBlIk Gauging Probe. MOdel: ---.M~. IJ Tn-Tank Gauging Probe. Model: Sa' Annular Space or Vlllllt Sensor. Model: Pibê.(§/au ",foil( ~ 0 Annular Space or Vault Sensor. MoGlel: & Piping Sump I Trcnch SeDSOr(s). Model:$w.u." .5ett r"y 0 Piping Sump I Trcm;h Scnsor(s). Model: Q Fill Sump Scnsot(s). Model: 0 Fill 5wnp SCJlsor(s). Model; I)J Mechanical Line Lçak Detector. Model: PL ¡J = C Meçltanical Line Leak Detector. Model: C Electronic Line Leak Detector. Model: IJ Electronic Line Leak Detector. Model: 1:1 Tank Overfill tHigh.Level Sensor. Model: _ 0 Tank Overfill I High.r...e....cl Sensor. MoGle I: o Other specify ~uipment type and model in Section E on Page 2). 1:1 Other clf,y equi ment Iypc and model in Section E on P~e 2). TllokW: "Z. J1,'<1t1 Taakm: r, In·Tank Gauging Probe. Model: -.Mà.~. 0 In-Tank Gauging Probe. Model: q¡ Annular Space or Vault Sensor. Model: ~(f+-'~ C Annular Space: or Vault Sensor. Model: ~ Piping Sump I Trench Sen~s). Model: 0 Piping Sump I Trcn~h Sensar(s). Model: a Fill Sump Sen$Or(s). Model: 0 flU Sump Sensor(s). MOdel: !it Mechanical Line Leak Detector. Model; --.f!¿ ¡J 0 McchanjgaJ Line Leak Detector. MOdel: C Electronic '..ine Leak Cctc:dot. Model: 0 Elcotlonio Line Leak Detector. Model: o Tarlle Overfj I Higb-Levcl Sensor. Model: a Tank Overfill I HIgt\-Lcvel Sensor. Model: o Other (5 cify eluipment type and model in Section Eon l'age 2). [J Other (8 if)' ~ulptnc:nt type and model in Section E on Page 2). Dispenser ID: 1-2 ... Dispenser m: ~ = QI DI_Coo,,'"_ _.). "'""'" vA' ~J AI'~ " D'......., """........t _,~ MO<ieJ, ~.,.( _.., 91. Shear Valve(s). at Shear Valvc(s). [J Dispenser Containment Plo~s and Cbain(s}. CJ Dispgnser Containment FIDat(s) and Chain(s). Dispénser 10: Dispenser m: aI Dispenser Containtnent Scnsor(s). Mode[: ~ [J Dispenser Containment Sensor(s). Model; ø S"car Valve(s}. [J Shear Valve(s). CJ Dispenser Containment Flo s and Chain(s). C Dispenser Contalnmçm Float(s) and Chain s). Dispenser ID: t'-, Dispenser ID: 13' DispCllserContainmcnt Sensor(s). ModeJ: v.A' ~~( Mitt' 0 Dispenser Containment 50nsoI(8). Model: at Shear Valve(s). C Shear Valve(s}. CDlspenscr Containment Float 5) and Ch~in(s), C Dis enscr Containmenl Float(s) and Chain(s . ·lflhe facility contains mOre tanks or dispensers, copy this form. Include infonnalion for evei)' tank and dispenser III the facility. C. Ceröfication " 1 certify that thl! equipment identified in this doeument wall InSfI.cted/Servic;ed in IIceordllnee with the manllruturer.' guidelines. Attaelled to thill Certification is information (o.g. RlInvfaC!turcrs' chCC!klisU) nceessary to verify th:d thil Information is COrrc~ and a Plot Plan showing the layout or monitoring equipment. For BDY equipment capable of a-enerating Juch reports. I have aIM aftached a copy oftJJe reportl (cJuck all drat apply): 0 System ret-up Q Alarm history report Technician Name (print): "23'Y'L.t..~é. 7J"LA~/~f,¡t.. Signature: _~ -I.....~ Certification No.: ..51; 1~~~7r Lçense. No.; ~/7r;) . ,', a Testing Company Name: Lk./-I./tYB.,ì&f ,%l.L~·lÞm~,~r Phone No.:Cffi..J.32 7-'l'J~j.;' ."~" Site Address:.!ILQL rr"-J(ru.v, A~, ~K1:,rJ-A'fda; C4.- . Date ofTestin~Servicing: lZ..../'J.f:?;Ì"iJ!t Bldg. No.: City: /S~ Key.sH'~/d Ce:... Zip: ?..7.:J~ . Contact Phone No.: ( ) Date of Testing/Servicing; 12./ / ¿I £Jt... MonitOring System Certification Page.of3 , ..'....~; DJID 1 -. .. -- 12/15/2004 09:48 6613252529 CAL VALLEV PAGE 03 t D. Results of TestinglServicing Software Version Installed: III 02_ c h in ck omp de t e Collow tg ehe list: ¡a Yes r:I No· Is the audible alarm operational? I Ye¡ D No. Is the visual alann operational? . J Yes _Q No· Were all senson¡ visually inspected, functîonal~ ~_ and conflI1l1ed operatIonal? I Yes Q No· Were all sensors installed at lowcst point of second8l)' containm,ent and positioned so that other equipment will not interfere with their proper operation? DYes CJ No· If alanns are relayed to a remote monitoring station, is all communications equipment (e.I. modem) t;iÞ NI A operational? Q Yes . No· For pressuri~ed piping systems, does the turbine automatically shut down if the piping secondllry containment Q N/A monitoring system detects a leak, fails to oparate, Or is elec:trically disconnected? If yes: whicb sensors initiate positive shut-down? (Check oll that øpp/y) þiiLSumpITrencb Sensors; C Dispenser Containment Sensors. Did you confum positive shut~down due to leaks and sensor failure/dlsconncction? f.iI Yes; C No. D y~ CJ No· For tank sY$tems that utili2;e the monlroring system as the primary tank overfill warning devicc (i.e. no ~ N/A meçhanical QverfiU prevention valve is installed), is the overfill warning alarm visible and audible at tlte taok fill po~ and operating properly? If SQ, at wh.at percent oftank capacity doeS the alarm trigger? % DYes· Qif No Was Bny mQnitoring equipment replaced? If yes, identifY specific BCn$Ors, probes, Or other equipment ,replaced and list the manufacturer name and model for all replac:ctnent parts in Section E, below. iii Yes. 1:1 No Was liquid found inside any secondary contalnntent systems designed as dry systems? (Check all that øpply) œJ Product; QI Water. If yes, describe caUSIt$ in Section E, below. ~ Ye¡ Q No· Was monitonng system set-up reviewed to ensuie p!Ot>Cr seUings? Attach set up reports, ifapplicable I.ßI Yes o No. Is all monitoring equipment operational per manufacturer's specifications? · In Section E below, describe how and when tlle..~e defic:fencies were or will be corrected. E. Comments: /JHI'-lhftVf H4,r.-'-<'- ,>T-a"~( A./lJhf! Se¡".('oy:ç~ IUfTA//",d M~t:.JfaHI'cA/_ lÙ,-e. ffa.,K' d~Hc:t:2tr. 0/~P~l1~fN' PAh ~ '3 -t¡ hAf '1." ðÇ }/t:P.LI'd'. Page 1 013 03101 .. 12/15/2004 09:48 6613252529 CAL VALLEV PAGE 04 r. F. In-Tank Gau,png I SIR Equipment: lit Check tbis box ¡hank gauging is used only for inventory con\rol. Q Check this box if no tank gauging or SrR equipment is installed. This section must be completed if jn~tank gauging equipment is used to perfonn leak. detection monitoring. Complete the followmg dteddist: CJ Yes I:] No. Has all input wiring been inspected fer proper entty and tennination, including tesli.ng for ground faults? (J Yes a No' Were all tank gauging probes visually inspected for damage and residue buildup? [J Yes o No' Was a.ecuracy of system product level readings tested? CJ Yes [J No. Was accuracy of system water level readings tested? o Yes a·No· Were all probes reinstalled properly? CJ Yes o No· Were all items on the equipment manufaçturer·s maintenance checklist completed? · In the Section H, below, describe how and when these defiCUUII:ies were or will be c:~rreçted. G. Line Leak Detedors (LLD): [J Check Ihis box if LLDs are not installed. Complete the Following cbecklist: ÇI. Yes a No· For equipment start-up or annual equipmenr certification, was a leak sÎmulated tQ verifY LLD perfonnancc? [J N/A . (Check a/I that apply) Simulated leak rare; & 3 g.p.h.; Q O. J g.p.h; 0 0.2 g.p.h. ~Yes. 1:1 No· Were all LLDs ccnfumed ope{ational ilnd accurate within regulatory reqUIrements? 1;'2 Yes [J No· Was the testing apparatus properly calibrated? 9i1 Yes a No· For mechanical LLDs, does the LLD restrict product flow if il detec:ts a leak? CJ N/A CJ Yes a No· For electronic LLDs, do~ the turbine automatically shut off if the LLD detec;ts a leak? . ç¡t NlA eyes o No· For electronic LLDs, does the turbine auromatieally shut off if any portion of the monitoring system is disabled fSl Nt A or disconnected? a Yes a No· For electronic LLDs, does the turbine automatically shut off If any portion of the monitoring system tw Nt A malfunctions or fails a test? Q Yes a No· For electronic LLDs, have all acc:essíblc wiring connections been visually Inspected? 111 N/A IS Yes [] No· Were all itCltl5 on the equipment manufacturer's maintenance checklist complered? . In the Section II. below, describe how and when these denclenC:le5 were or wfIJ be corrected. H. Comments: Page J or 3 03101 12/15/2004 09:48 6613252529 CAL VALLEV PAGE 05 Monitoring Sy~tcm CorfJfiC:IUioJ'l UST Monitoring Site Plan Site AddreJl~: if / () / TV(..LJo'°k.J:/ Akt. .ß4..k'~..rA'oi1:(j ("',¿t.o ---- o ~. . Cl" . 1/- ,.£. .,...,. 00 ~ ?-I OD · . .. . I 0[§J';,t.~~: :'. . 'Å_: 0 . . . · .~t.... · . . . I . . . L: ::; ~. U · ,. .... ...... · " .... .,.... · . -. --........I. '" · . .. ...., .... . JHø-..¡ 'tv-r . :~6 , r..:,¡.¡.. (" . .1:1"*,,.;141" . . . . Dale map was d'a~yr¡: .1ZJ I) / or, InstructiOllj If you already have a diagram that shows all required infomlÐtion, you may include it, ratJ1er than this p¡lge, with YOllr MOl1itoring System Certification. 01'1 your site plan, show the gencral layout of tanks and piping. CIc.aI'ly identity locations of the toltowjl1g equipment, i f in~ta!lcd; monitoring system control panels; sensors monitoring lank annular spaces, sumps. dispenser pans, spill containers, or other secondary containmcnt areas; mechanical or clcc:t'()nìc line leak detectors; and in-tank liquid Jew probes (if used for .Ieak detection), In the ~pace provided, note the d;He Ihis Site Plan was prepared. PlIge ïorL CI;;IPQ 12/15/2004 09:48 6613252529 GAL VALLEY PAGE 06 V APORLESS MANUFACTURING, INC. Contractor LDT~890 Leak Detector Test Record ~'m[ Ctll/-u..J/~" E,?-Ú."~htl!.hj- Date - LocatioQ . &'K-eV5-h ~J¡;/ C/I;:/ CtJYA Y4V'd' Product /2."¡.J -f) If Iechnic~ !..¡/Q/ 7Ÿw..ýt-Lt¡,., Av~ 13NC~~·.,,/~rð.. ~7VL ..ß1"ùL~ )h'j'1S/{,LI Manufac~ Submersible Pump Identlficøtlon Model No. Serial Number Lt=. PtTY'"O Manufacturer Leak Detector Identification Descriotion Other St'\rJe Leak Detector J2e.d Lkdk-l~ Diaphragm.typc_ Piston·type ¡,-- Tampcr-proof$el.l installed? Yes No Leak Detector in Submersible Pump Test at Dispenser 1. Operating Pump Pressure :2.~ psi (para. 15) 2. Gallons per liour rate :3 (para. 22) 3. Lint pressUfe with pump shut off /J psi (para. 23) 4. BJeedback Test with pUmp (Iff ,,~ mI (para. 26) 5. Step-rbrough time tQ fuD. flow :J seconds (para. 30) 6. ,Leak detector stays in leak search position. (para. 42) Yes L-- No_ LEAK DETECTOR TEST Nole: a-ass = leak delectar fila lest )lQIOa) Fall ;; Leak d~eClor !ails test prglocol Pass_ V- Fail Form 890C (9- J -96) ·CompJete thennal expansion test before failing leak dctèctor. 1996 Vaporless Manufacturing, [nc., Prescott Vallcy, AZ .. 12/15/2004 09:48 6613252529 CAL VALLEY PAGE 07 v APORLESS MANUFACTURING, INC. Contractor LDT-890 Leak Detector Test Record Customer CA./- t/a.//<.r..¡ ~ÌA-/pm"J'''' Date Locati!m. ß~k'e.i'""~"c¡t-hIr'" C/t:;J C~rA ~a.~ ~ ~2-/.3-0~ 1-/10/ TY"'-'¥rù.", Ave. Bak-ev.$'¡:¡~ Lk.- Technic:t:ln L:)¡~-e/ ßv-c..£ù£. ¡'¡'ins/~y Manufacnuq Submenlble Pump Identification Model No. Serial Number f:: ¡;. ¡f)e f1'^o Manufactuter _ Leak Detector Identifieation IlcscriDtioD Other Style T .p.ak DetectJH --.e~(P.Ck~T' Diaphragm-type___ PÎsto~ V- Tamper-proof seal Îr1staUed? Yes No Leak Detector J) Submersible Pump Test at Dispenser L Operating Pump Pressure '2 usl (para. 15) 2. Gallons per hour tilte 3, 3. Line pressure with pump shut oft /"1 4. Bleedback Test wíth pump off /"0 S. Step-through time to IùU flow_ :3 , (para. 22) usi (para. 23) ml (para. 26) seconds (para. 30) 6. Leak detector stay¡ in leak "arch position. (para. 42) YCS....f::::::.... No~ LEAK DETECTOR TEST Note! '-!IS -- teak det=or fib &est protocol F.II- I...cIk detector ßlils lest ProlDl;oI Pass I/"" Fail Form 890C (9-) -96) ·Complete thermal expansion test bcfore failing leak detector. 1996 Vaporless Manufacturin¡, Inc., Prestott Valley, AZ