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HomeMy WebLinkAboutBUSINESS PLANi. MERCY I30SPITAL - ~ i „3215 TRUXTUN AVENUE FROM :I3SSR, INC C . ' .. ~ ~ FAX N0. :66152786 ~n •~-aro~ lI'i3 ~~ Nov. 13 2006 11:11AM P2 • 11~YaNIT0RING SYSTEM CERTIFICA-'~''YON • ~br [Ise t9y All JutsrdictIuas IPlthut the .Stutz of Califarnla • .4uthar(tv•Citet/.• Chrrprrr 6 7, Neu(th and Safery C'udg; Chupter /t5. prvirlut 3. Tlele 7.3. Culifurnia C~xlr vjRegatariurry ' This form meter be used to document testing and setvicing of monitoring erluiprnent. A Retsarate certiftcati r repon mpst be orep~ for rach_ mon~rinQ system oontral cane!. by the technician who performs the work: A ropy of this form must be provided av the tank • ;~yscctr owner/opgator. -['he owttodaperrtar must submit a copy of this form to the Local agency regulating U5T sysitms within 30 days of test date: A. General Infartxtati ~~,r • Facility lYatne• ~~f/`/,~,~ Sld . No.:_.,.~_w 'Silo Address' .~ ~r Cie • - y Zip: ~acllity Contact Person' Contact Phone No.• ( 1 MaicelModel afMonitoring System: ~~ 1-/~~-~r~ f7ate of Testiag/Serv4cing: ,~1~/~ . R. invrnMrjr of 1 Tastgd/Cal~•titied Taah IDi• ~ Tank ID: _ _ -- ^ Ia-'I'aalc Gtutgiteg Ptnba Model: ^ Yn-Tank Gaug3ttg >~tobe. Model: ~Attttalar Space or Yana S~sor. Model: ~ O Anmtlar 3paca or Vault Sensor. Model: ~i'iPiping Swap ! Trencl- Satuot(s). Model: C] Piping Sump / "E'eenclt Sensor(s). Model: Q FIU Sump Sensor(s). Made1: D Ell Sump Sensor(s). Model: O Mechanics! [.iete ~L.eak Detector. Model: D Mechanical Lam Leak Detector. Model: Q Slecu~ottic Lieu 4eak Detector. Model: _ O Btecuotdc E.Ine I.ealt Deteexor. Modet: a Tank ClverHll l High-txvel Sensor. Model: O Tank pwerfiU / High-level 3easar. Modal: O Outer ui nt artd model in 5oction S on e 2 O Odler ui t and mode! in Section E ort Pa 2). Tattle ID: ~_.•,._ Tadt ID: _ A En-Teak Gauging Probe:. Model: O Is-'Ink Clanging Prole. Model: q Annular Spas or Vault Sensor. ~ Model: ,...__ O Maurer space or vault Sensor: Modal: O Esping 3wnp ! Tibett$ Sensor(s). Model; q Piping Sump /'!tench Sensor(s). Model: O ~ Fill Surnp Senaar(B). Modal: ,,, O Hilt Su ~ t d Mechanical lice Leak DeoeCtor. Model: Crt Mechs~ti ral L,calc DetecLpr. Motlcl: I] F.leceronic Liao teak DeeeCtar. Model: G~ Sleeaonfc iiriG laait Detector, Moc~l: O Tatdt 0verF1! / fliglt-Larol Sensor. Nortek _ __ D Tank Ow~ill / Iiiglr-[,eve[ Sensor. Model: D Other UI ilt t sad plpd4l. in Section S on Page 2)_ Q Other (snecifv tauioment tone and model in Section E an page 21_ Dlspettser ~: Disp~er ID: - - -~ O DispenssrC.otttaiamd~tSenaot(s). Model: _ ©17ispensecContaiatttentSensor(s). Model: 0 Shear Valve(s). ~ O Shear Valve(s), O Di Coetaidrncnt Floe s and Chtda s). Q pi n3er C:ontautrnent F7 s) and CJtain(s). r ~ -_ _ Dispenser Ill: __ _ O Dispenser Containment Settsat(s): ModeE• • ~ O Dispenser Conraimaacr-t Seasot(s). Model: ~ O Shear valve(s). D shear valve(s). D C:oaCainment Floe s attd ~ S . . O 1?i Containment Flo Sand Certain s . Q Dlspett9er Catca4narettt Sen'sorts). Model' O Disperuor Containtrteett Sensor(s). Model: _-- O Shear Valve(s)' 0 Shear Valve(s). •If tqa facility t:ontaiets more tanks or dispmseea, copy this form Eneluda ulfarst~atian far every tank and . tlispeaser at tote facility. . C. Celrtil~est3txi - [ +xrg4T ttutt fire agvdpaaent isderttilfed i>: rids document was b~iected/serviced is aecorelaace with the mattwLacha~ers' guideliaea. Attitdted to rids Ctrdgeatloa is itlt'bsmatio>a (eg. tnantlCaekurcyes' checlctlsts) rtetr~ry ao veri~ that trila information is comet altd a Pbt Pign a6owGtg the Iayont of tnonltot•Ing tequipment, Par any ega3pntent capable (' gt~ttetating such rte, [have also atta~4ed a copy of the ~ei~ t !~ System set-uP ^ # . Technician Name (prlgt). /~ - , , Sigtuttuce: , ~ ~ C.ettiftcatipn Ho.: !/f~?' ~ t/J ` Testing Company Na Site Addtrss:•~~ Monitotiag System Certiiiieatton Y.icetise. No Page t o[3 Phone No,:(! ,,,~].j~d ,~ Date of Testir-g/ServiCing: 03!01 , FROM :BSSR,INC FAX N0. :6615882786 Nov. 13 2006 11:12AM P3 ~~ D. Ress~lts of Testing/Servicing Su[tware YerSion Installed: t^amdete the lollnwle~ checklist: Yes Q No" [s the audible alarm o rational?' Yes q No# Is the visual alarm o ratianal? Yes !vo• Were at[ sansots visuall i led, ftutctionall tested, and confirmed o rational? • Yes O No• Were ail sensors installed at Ioweat point of secondary contaiYlmant and positioned so that other equipment wil! ~: not interfsze with their r cion? O Yes q No,*~ If alarms are reiayad to a remote monitoring station, is all communications equipmxnt (e.g. modem) operational? O Yes ^ No" Fqr ptessurixed piping systems, does ilia turbine autgmaticttlly shut down if the piping secondary containment N/A matitoring system detects a leak, fails to gperate, trr is electrically desconnected? If yes; which sensors initiate positive shut-down? (Check all that apply) O 5umprl"rench Sensors; D Dispenser Containment Sensors. Did cottfltm itive shut{Iown due to leaps acrd sensor [ailureldisCOnnection? O Yes; O No. D Yes q' No's, NYA Far taAk systems that utilize the tnanitoring System as the primary tank overFl! warning device {i.e. no mechanical ove~F1 proveaGon valve is installed). is the ove~ti wattling claim visible and audible at the tank glt is s and o ratio rl Ig sa, at what t of tank i does the alarm r? 9io O Ycs* No 'Was say motutoring egtdptnettt replaced? If yes, identify sptcitic sensors, probes, qr other equipment replaCDd and list the ttlanufacturer Wattle and model for all lacemeat in Section 8. below. O Ye~• ~ No was liquid found inside any secondary eontait+tnent systems designed as dry systems? (Check al! that apply} Q Produce; O water. If es, describe causes in Section 8 below. Yes O NO• Was [U4nltDri s rein set reviewed to ensure Settin ? A2taC set p re res, if livable Yes O No` Is all monitatin ui mint 'ono[ ttuurufacttaer•'s s iEicatioos? A4. Vr~MVN L' Y~.IVw~ yGIYa.V~. a.Y ANV ,. MrN rWV NwwVYtiiW ..+Nr V. .. a,. w ~..~aw~VY. E. Comments: { FROM :BSSR,INC FAX NO. :66152786 Nov. 13 2006 11:13AM P4 .~ . ~ ., F.- Iq-Tank Gaagirxg !SIR EquipmeaC~~ACheck this box if tank gauging is used only For inventory eonu•al. ' O Cltnck tFti~ boa if no tank gauging or SIR equipment is installed. Thos section must be completed tf In-tank gauging equtptnent is used to perform lt:tilc dt:tecaon momtonng. c;om t o roe iouo wt caectaist: O Yes D lYe* Has aft input wiri>ag been inspected for proper entry and'termination, including testing for ground faults? O Yes Q Nv* Weir'sll tank gauging probes visually inspected for datrrage and residue buildup? O Yea O No* Was accuracy of system p,dduct level readings tested? Q Yes {] No* Was aaxezaay of system wain Eevei readings tested? O Xes Q No* Wece all probes reinsralle¢ properly? O Yes O No* Were all itectts ort the equipment tttsnufacntc+er's tttaintettance cftec[ctist completed? * In the S ection liL. below, describe how and when Were det?tr3ceeies were nr wlll rye mi'1'P.~int_ G+ Lice Leak Detectors (L~,D}i ~ Check this bwt if LL17s aro not insiallcd. .~ [` - - il^a rnanvrtns wt~r.lriivle Q Yes C7 No* For equipment start-up or agnttal aquipmrxit cettd' tcatEoar was a leak sunnlaood tp verify LI.D performance? 0 N!A (Check af! that apply) Simulated leak rate: O 3 gp.b.; !, 0.l gph ; Q 0.2 gp.h. 0 Yea f] No* Were ail i.[.US confu'med operational and accurate within regulaaxy raqu~~~*;7 Q Yes O Ne* was the tescitig apparatus properly calibrated? . D Yes • ^ No* !~or mechanical LLDS. does the LI.D restrict product flow if ie detects a leak? o NrA • D Yes O Ne* For elegy I.L.Ds, does the turbine automatically shut oil' if the r.i n detects a kak? O NIA " " Q Yes C7 No* For dectmtric LI.L18, does the tttrbare sutotnatically shut off if any portion of the monitoring system is disAbled © NIA or disaoruiccted? ~ ' fa Yes O No* For elecavnic T -T.~ does the ttirbiae automatically shut off if any pot~prt of the monitoring system malthnedous O N/A or Pails a teat?'. ~ • D Yea 0 Ne* For electronic LLDs, have all aCCessitrla vriring connecaoas been visually Inspected? D NIA D Yes O No* Were all items on the equipnrettt raatrufacturar's maintenance checklist cotrrpleted? w tae xcaon ti, tieiow, aescrrue now aria when tateBe de>gcieticies were or wilt be eot~rected. 1~ Commeats; . rage 3 oil a~ot ROM :BSSR,INC nitoring System Certi~icatton Site Address: FAX NO. :6615882786 Nov. 13 2006 11:13AM P5 ,' •.` UST 1VXo>u,itax'ing Site Flan . .~. _ . ...... .:...P~~vtr:... ........ ....... .......... - -~- ::::.~ ..:~a:::::::::: ::::::::::::::: ::;:::::::::: . Hate trap was dxawa: ~_ , -,,,,•! . .. Xns~ue ons if yott already have a diagra:n•~sat.'shows all required information; you may include~it, rattiier than this page, with your Monitoring Systerrt Certification. ~On yout~site plan, show the general layout of.tartlcs and piping. Clearly identify locations of the following: egttipment,. if installed: mor:itofsng system. control panels; sensors monitoring tank annular spaces, sumps, dispenser pans, spill con#ainexs, ar other secondary containrrtent areas; mechanical or electronic tine leak detectors; and in-tank liquid level probes (if used for leak detection).., Yn the space pirovided, Hobe the date this Site i~ian was prepared. ~ ', pa;e / of _~ nsr4o FR^M :BSSR,INC FA}C N^. :6615882786 Now. 13 2006 11:14AM P6 • ., SWRCB, 38nuary 2006 . Spill Bucket Testixxg Report Farm• . 71Qis form is intended for use •by cvntracdors performing irnratcrl testing of UST spill containment structures. T'he completed form and . printouts from tests (f g~plicable), should be provided to the facility awr~r/pperator for submittal to the local regr.~dtpr y agency.' f_ FACli.iTV iNTtrA~nrss~rrnN p'aciiity•FTame• Date of Testing. Facility Address: Facility Contact; -„ 1'hgne` ` '. Date Local Agency Was Notified of Testing : ,~,~ ~ `~ • Name of Local Agency Iuspec:Gor (if pr'es'du a'rviMg tasting: ~ . ~' z.. ~cTrlxr_rnN~rusr-~rnu nvFnrr~rs~rrcaw •. Cou:panY Name: .'~ • Technician Conducting Test: ~r '" Credentials': O CSi.aB Contractor C Service Tech. ~ SWRCB Tank Tester Q Other (Specs J _.... _~_ . License Numbers): ~ -.(,( ' 3_ Sriii.i. RiT!`KF.T't'~C'1`YN~ 71v12:t')RM~I'I'f(1N Test Method l7sed: drostatic ^'~actium - ^ Other . Test Equipment iTsed: went Resolution: Identify Spill Bucket (By 1"a,ak 1Yurnber, Stored Product, etc. 1 f/ ~ z 3 4 • Bucket.l'nstall$tipn Tie:, B~'t3' ^ Contained ia,Sum 0 Direct Bury O Carrtained is p 17iirect Bury . ^ Contained m Su ^ Direct Bury C1 Contained in Sum BucketDiat~ieter:.• . . ..Bucket Depth: ".. ~ . ~/ wait tirr,e between applying V'acuum/water and start of test' • ..Test Start Tune {'Tt?: ~ ` . Initial leading {R~: ~- Test Eud Time (TF): ~ ~' . Final Reading (Rp); ' ' Test I]ur'atian (TP - T~: Change in Readnng (R~•» R~: Pass/Fail Thresl-old or . Criteaia: ~ - Test ReBlrlt: Pass O Fail . ^ Pass ~'.[~ .I+'ail. ~ ^ Fans ^ li'all ^ ~ Pass ^ Fail t.v4amenss - {inctuae irerprmattoh ore repairs made prtgr to testing and recommendedfollow;upforfailed tests) C1rIiTIFICA'FION OF TECEII~TICIAN Y~SPOIVSIBLE•FOY~ CONDiJCTIIYG THI5 TESTING I hereby cent that atI the ii{~ntmatlort Coittairled lit this report is true, accr~rate, and bt fttll• conipllance with'leggt requlrentertis. Tec ''cian^Signature: ~f~ :~ ~~` 1 ^.. ~• ~,"~'~ ••dd i State laws aad regulations do not currently neq~iire testing to be perfisrmed 63' a qualified'contractor. However, local requirements. mQU•ha n~nra mpinn~~ FROM :BSSR,INC FAX N0. :66152786 Nov. 13 2006 11:14AM P7 Ong System Certtt~tfam ~~ Ad~duamter V'~uammiPree Taterstttial Bananas LG 163.1; F.nc. llY L it+e~dts c~ V ~uziag uee~oi# Ted . This page shonid ~e used to doctument testing and servicing of vacuum and pressure interstitial sensors. A copy of ti?is foam anttst 6e included with the MaAit+oring System Certification Form,. which must be provided to the tank system owaerloperator. 'T1a~ owner/operator mast stlb~mod a Dopy of~ the Monitoring System Certification >?ottn to the local agency regulating [tST systems within 3D days~of test date. ~. ~: . ~ ~~~~ ` Ft' the ae:lsor suooesafulty detects a simulated vap~,essure leak introduced in tha interstitial space at the furtteast point from the 9ed90r, VBCElt>m/p1'~SSQ['E 118.5 been'dtcad b0 isG ~co=ttittunicatittg t!n'QUghalut tine intex'sfrCe. Envy vaas•~ ves~dx (~ Leak Iatroc'luced st Far 8nd of Iiat~erstitial ace; ^ G'isv Visual In 'o»;. .0 Othca {Describe in Sec. 3, bei4w} . Vacuum was rea~ee~ to opeevdiag lauds ie slt in#e ^ Yoe ©. TJv fEf nv, describe in Sec. J, bedi9w} FROM :BSSR,INC 6830 Rosedale Wwy d! B ~lc8refie0d. (~amia 9:1308 Phone: ~G15682777 'Fax: $&i'$H$'2785 Fax Ta: S Unciet+xoed FAX N0. :66152786 Nov. 13 2006 11:15AM P8 BSSR, Inc Rron~ Kristine Faic: 8S2 X171 Rlatec 11/13/06 Plt~ne: Pages: 7 iiiDa Mer+Cy HoSpltai 4Q0 Oid River R:~: Wermit TT-d23 Fue! Monitoring Certification ~ ;~ Fa »r ~ Pk Crooasn~rt ~ P1e~se ff'dBply f3 Pie Ita~y~ale FROM :135SR,INC FAX NO. :6615882786 Nom. 13 2006 11:15AM P9 • ~.• 1Yit)NTTO1tING SYSTEM~C~RTIFICATION • - _ ' ~ For Usa By Ali lurl~dlirtktt.>• Withl~r rite Stole o,~'Grlifnrnlu • .4utkurtty CitCd° Chuprer 6.7. Health anr! Safary Cvde: Cltuptrr l h. Divftlan 3. Title 2.i, Calljarniu Crx/r of Regulations ' This farm must be used to document testing and 5erviCiag of monitoriaig~oquipment. ~,~~ rote iarrtift~:ation or report must be ane~arod. Pore h mon~torin¢ s stem ~nerol ,~:txE by the technician who performs the work. A copy oP this Form must be provided to the tank yyscem owreerloperttor. 1'hc owner/operator must submit a copy of this Form to the local agency regulating US"T systems within 30 days. of cost dots:. . A. Gene~i'ai Inf Sion Facility Narttt: ~ //~~ ~~ $1dg. No.: Site Address: City: Zip ~T~~az FaeiltZ'y Contact Petswr ~ Contact Phone No.: ( r ' .), MakrJModei of Monitoring y . ~ ~ }~-- -~~ date afTesting/Servicing: ~.~Q~ B. Ytlventory of.Equiptanent es CeJrtefi ~~`~~ '~~~~' ..~.....o. Tank•ID: - - ~' - Tank ID: In Tana ' g PtoBe. Model: Q Ue-Tmdt Gau~rt4 Probe. Model: graattrlar Space or Vautt Senarx. MadeR ~7 Annular 3paoc or Vault Ser-sor. Model: D FSping Sump /Trench Sensors?. Made1: Q Piping $trrnp / Tatsach Sensor(s). Model: _ -- _ _ - ~[ill Sutap Seosot(s} Model: " Q Fill Sur: Sensat(s?. Model: Mechanical Lind Leak Detector, Model: - ---- •. O Mechanical Iatu Leak Detector. Model: O E[ectroaic Liao Leak Detector. Model: ~ Q .t;lectrr,aic Line It;ait Detector. ~ Model: a Tank Overfill t Hi~Level Sernto< Model: O Task Oveefill I Nigh-Level 5ansor. Model: Cl Others ui sad in Section fi on P ~ Z . O Outer s ui nt and nwdel in Section fi on 2 . Tana ID: t Tank II3: • O Eta-Toole Ciattgiag Hobe. Model ©In-Tattlt Gauging Probe. Made1: ,~ Annular Space or Vault Sceser. ~ Model: - r ©Annular Specs or Vault Sensor. Model: ' ' Piping Surnp / Trench 3ensat(s). Model: t7 F-;ping 5~unp / Troach Sensot{s). Model: • Fill Sump Setssot(s). Made1: 0 Fll Sump Sensor(s). Model: O Medtarrieal Lire Leak Detector. Model:• O Mechanical Llrx [.oak Detector. Modd: • O Fleetronio Lute Leadt Detector. Modal: O Elsctronic Line Leak Detector. Model: O Tanit Ora4~ll / high-Level 5ertaor. Model: d Tank Overfill / High-level Sensor. Model:.-...-- _-- ----------.. _.... ~. O Otter (s i of t [ and madet in Section 8 on 2 . O Other (s of ui t t and model. iai Section E on e 2 _ Dispeotosr Iri: Dispenses' lA: . Q Dispenser C,ontaitrttterttS~nsor(s). Modd: -- _ -- t? Dispcrascr Certairstaent ScnSOt(5). h~iodel: D Shear valve(s). ~ shear Valve(s). ~ ~. O Di Cootaittrnent Floc s aatd Chaff s). O Di Coataintncrtt El s) and. Ctain(a . Dispenser ID: ID: d Dispenser Cotttaimetent Seasa(s): Model: -- -- _ ~ O Dispansa Contaiitroent Sensor(s). Model: • O Sheer Valve(s). '. Q Shear Vslvr(s). O DIs r Containment Floats attd a • D b' Caaaiament Floats at7d Chains . Dec ID: Dlspettser ID: D .Dispenser Contalnmptt 5eosor(s). Modal: t7 Diapensex Co'ntsimneat sensor(s). Mudd: O Shear Valrre(a). CI Slicer Valve(s). ODi aserCoataigd-eut FlOat(9 atld S O' Di Containrtaent sand Choi S . . +If the facility eontalas'motti tanks or disoensera. onnv this farm. Include i nformation for every tattle cad distxrtser at rite facility. • C. Ccit'H##catton • I cestl(y chat epee egntputeut.tdenelfled [n this doautetxtt urea ltt~apectedlttanvieed to aaxordeutce vrith the toauutacettrets' gttNdeHeres. Attadtetl to this Certllltatlan la information (e.~. tttattutactterecs' checWists) »et~ary to verity that this informritlon i$ eoft'!ct surd to Plot lrlatl 01lOwIo$ the lapse of rttodtoHng egtdlxnen6 ;tor arty egtilp rspab of ger>eratiog Sundt reports, i have also attached a oop~ oCthe ne~p~- (, art tbat h O 5yscem set-ap O 1 p ~ ~ . Teehrtician Noma (print): Signature: ~ 7 +_ r Certification Pip.: ~-G~.~--~ License. No.: ~//j~Z"~l ~ Testing Compaey Nattu• ~ ,.rte e No.:~~~J ~- Site Addr+ese: r3o f/ ~`" ate of TestietglServioing:~~,f _ ;"age i ol3 031st MoniWrlttg 5ystetn Certli'lcatioa ' FROM :13SSR,ING FAX NO. :6615882786 Nom. 13 2006 11:16AM P10 D. Resells of Testing/Servicing SaRwure Version Installed; ' ['n.nnletw [IfQ CnRnwinv ~hazlctiat_ Yes O No* Is the audible alarm a rational'' Yes Q ~ No* Is ttte visual alarm o rational? Yes ^ No* Were alt set~ors visualE ins ced, funcdonalt tested, and conFunted o eradonal? Yes ^ No• Were all sensors installed at lowest point of secondary containment and positioned so that other equipment will not iptrrfere with their ro r o ration? ^ Yes ~O No* [f alarms aro relayed to a remote monitoring station, is alt communications equipment (e.g. modem) NIA operational? 0 Yes D No* For pressurized piping Systems, does the turbine autornntically shut down if tt'JC piping Secondary Containment IWA monitoring system defects a leak, fails to operate, or is electrically disconnected? If yes: which sensors initiate positive Shut-down? (Check all that apply) ^ Sumpt['rench Sensors; d Disptnser Containment Sensors. . Did on confirm sitive shut-down due to leaks d sensor fatlure/disconneaien? 0 Yes; ^ No. . D Yes ^ No*' For tank systems that utilize the rrtonitoting system as the primary tank overfill warning device (i.e. no N!A tttecltanicai overftll prevention valve is Installed), is the ove~ll wanting alartn visible and audible at the tank Pill in s and tin fFso, at what toent of tank ca it does the alarm tri tr? 96 O Ycs* No Vvas any rnartitaring cquipttaatt feplaced? If yes. identify spodfic sensors, probes, or other equipment replaced and list the manufacturer name aad model for all ro lacement in Section & below. Q Yes* No Was liquid found inside any secondary eanminnrerrt systems designed as dry systems? (Check alt etiat.apply} Product D Water. If .describe causes in Section fi, helew. Xes D No* Was monitorin s stem set-u raviawed to e~nsvre ra setdn ? Attac set re , if livable Yes fl Na* Is all tnonitorin ui ment o tional. manufacturer s s ifications? * i[n Section E below, deseri4e ~+ atfd whsn these de,Hciencies were or will be corrected. E. Comaneats. Page 2 of 3 Oal'Ol FROM :BSSR,INC FAX N0. :6615882786 Nov. 13 2006 11:17AM P11 . ~ F.• ••In-Tank Ganging / SYR Equipn>Eeat: ~ ChtCk this box iP tank gauging is used only for inventory Control. • ©Check this bax if no tank gauging or 5IR equipment is Installed. This section trust be completed if in-tank gauging equipment is used to perform teak detection monitoring: t."GA1 leo e the f08o wIA c3teclsllstt Yes O Pin' Has atl input vririttg been inspected for proper entry and termination. saetuding testing for ground faults? Yes D No" Wete'sll tattle gauging probes visually iaspecmd for damage and residue buildup? Yes I] No' REas accuracy al system product Level Headings nested? ' • Yes Yes O No* O N4* was accuracy of system water level readings tested? ' Wete all probes~reittstallad properly? • Yes • In the 5 Q No• Were all items on tht; equipmene ntanufacttuer's maintenance dtecklist Completed? ectlou H. below. d~rtbe how and when these de$t$eriC3es were or will be corrected. ' G. Line Leak DeteCtu~ (LLA): ~~ Check this box if I..E,Ds are sot ;nstalled. - - - -' - Co the roLO wut caecttttst~ O Yes ' O No* For e~ttiptttent start-up or annual equipt~ oerdficatiott. was a kaFt sitttutaoed to verify I.I.D perfatinanoe? D N!A {Check ali that apply) Simtilsted leap rate: O 3 g.p.h.: O o. l g.p.h : D 0.2 gph, Q Yes t] Pin" Wets a;11 t i iSS cotd4rttcad operational and accurate wlthla regulatory trquirements? la Yes 0 No* was the testing apparatus properly calibrated? ' U Yes • O No* For tneohattiCal i~I.Ds, doe8 the LLD tEBtciCC prodtta flow if It detects'a lea1C? O N/A 0 Yes Cl No* For electronic LI.I:~s, dace dse ttabirre automatically shut off if the LI.U detects a lcak? ~ ' D N/A • . l? 'Yes ~ No* ~ electronic LLDs. does ttte turbine autotuaticaliY shut off if any pardon of the monitoring system is disabled O N/A or disconnected? ' D Yes p No* Pvr electronic 1.I.Ds, does the turbine automatically shut off if say portion of the tt'eortitoring system malfwrctions C3 N/A or fails a test? , O Xes O No' For electronic LLDs, have ali accessible wiring conttectioas been visually inspected? ' D NIA D Yes O No+ Were aU items on the cquiptt~eat mettufaCtttrcr's maintetuutre checklist wtapkted? * Yn the S ection H. below, desCdbe bow sad wbea these deigcieatles wcn or will be otstrccted. H. Comments• ~ Page 3 of 3 oarot ROM :BSSR,INC Moaitortng System Certlflcstlon Site Addt~s: Y3S'~' N~o>aitoring 5xte Plan FAX N0. :6615882786 Nov. 13 20@6 11:17AM P12 ' ,' ,. , ... ~~. ::: r~:~ :: ~ :: :~ . ~ ~ .::.. ... :~~~, . ~ :::::::::::.:::.~ .~ ..... , .. .::..:........ ,mac ....:.:::::: ~ .- .:.:. . ...... _ . :: orb ~p ;~......:::::: ~ ::::: ' :::::.::::.:. .,. ~ .: ~~ ]~$oa map. wss'mawu¢ ~ ' ~ - . _ .. ... .. ~ ~ tf you already have adiagram that. shows stl required iafo~tmation, you may include it, rather thasu this gage, with your Moaitoriag System Certification. ~n your sine plea, show the general Payout of tanks attd piping. Cicarly identify locations ~o£ the fallowing egiiipaneat, if iastall~: monitoring system control panels; sensors monitoring tank annular spaces+ sumps. dtspcnser Pans. spi11 ~• ar other se~darY oontamme~nt areas; meclzaxucal ar etectronio line leak detectors; attd i~tsuk liquid tev~ probes (if used for leak detection). Xn tl~e space provided, tsote the date this Site )'tan was prepared: ~ . page ~ of O~ osroo ° FROM :BSSR,INC FAX N0. :6615~27B6 Nov. 13 2006 11:18AM P13 • SWRC]3, January 2006 Spill Bucket Testing Repoart ~orrn Thrs form is intended for use lry conrradors performinig manual testing of UST spilt coraainment structures. 1'he completed form and printouts from tests ({f'appliaable), should Ire provided to fhe facility awnc~^/operator for submittal to the local regulatory agency_ ' I. FACII~X1"Y INFORMATION Facility Name: Facility !#ddress: )~'acility Contract: Thane: of Date Local Agency Was' Notified of Testes Name of i,ocal Agency Inspector (:f preseirt during testingl: _- - . corrr~-~roR Ca Name: S /C Technician C~ducting Test: Cradentialst: D CSLH Contractor CC Service Tech. ^ SWRCB Tank Tester ^ Other~{Speci) License N'urnbetta): ~ sz~.Y. yairrurrT ~crnvr_ nvFnrr~e•rr~i~T Test Method Used: static • 0 Vacuum ^ Other Test Equipment Used: ~ Equipment Resolution: .... .identify Spill bucket (Sy Tank' Number, Stored Produce, eta 1 /f •.~~iG ~~ ~ 2 3 ' 4 . Sueket Installation Type: ~rrect Bury ~ ~^ Coined in S D Dir+sct Bury Q Cvntsinad in S ^ Direct Fury C3 Contained in S II Direct Bury t] Containael in Surer Bucket I7iameber: ~~ ' .;Bucket Depth: ~ ~ fr ~ . wait time betvKeea applyuig vacuum/water and start of test: Test Shirt Time (T~: init~l `Reading (Sr): Tess End Tune (Tp): ~ `• r Fibal Reading (RF); "~'° Test Duration (TF - TF): ,~/ r . Change in Reading (Itr,-ltt): . i?assJFail Threshold ar ~ Criteria: ~~ . Test result: ~ ass ~ t] Fail ^ Pass L7 Fail ' ^ Pass ^ Fail ^ Pass' ^ Fail C:•omm~rit5 ~ (include In ormation oa repairs tatade prior to testingand recammetrded, follow-upfor jailed tests ' CBRTIFiCATION OF TFCHPIICIAN RESPONSI~JI.~i~ FQR CONDUCTING THIS TESTING I hereby Certify that all the information coxtained !n felts rt;port is ,accurate, er>rd ut full Coutpllance with legal r+egatlrremettts Technician's Signature: ~~ Date: ~~`~ r State laws attd regalations do not currently require besting •GO be pctfarmed 6y a qualified contractor. However, local requirements mAV, ~'W mnTP alY7MIYpMt FROM :BSSR,ING ~ FAX N0. :6615882786 Nov. 13 2@06 11:18AM P14 Monitoring System Cert~tinn Farm: Add~rsdam fw'lTacvmoll'ressure Ynterstitiai Sensors LC 163-1, Enc. II • ~. ReSU~ts of Vat~u~t>,z~ssiu~e 1Mui~iitortrtg Equi~m~tt Tes#ing This gage should ba used to document testing and servicing of vacttum and pressure interstitial sensors. A copy of this form must be 4ne[uded w[th the A2onitoring System certification Form, which must be provided to the tank system owner/operator. The ownedoperaxor must sRbrttit s copy of the Monitoring System Certification Form to the Incai agency regulating LIST systems within 30 days of test date. 1. Comments: /P ci,/~ - r ~~~C , Psge of '' If the sensor suocassful]y detDcts a simttlatetl vaCuurn/pressure leak introduced in the iaten3titial space at the furthest point from the sensor, VAGU1nt7/pregSlu'e has been demrenc,rnte•ri to be cotnmunicadns thrqughout the interstice. 'fYaw eras icaesBgtlai ca~aao~nication vet~edT. ^ Leak Introdtx;ed at Far End of InterstiAal Space;l ^ Gauge; ^ Visual Inspection; ^ Other {bescrEhe In Sec. J, below) ~aenrmn was~restored o0 4peratl~tg levels in all interstitial ~= ©Yes ^ No (1~ reo, dea~cribe in Sec. J, below)